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CASE STUDY I-4

Supporting Mobile Health Clinics: The

Children’s Health Fund of New York City

The Children’s Health Fund

The Children’s Health Fund (CHF) develops and supports

a national network of 22 programs and two affiliates in 15

to 17 states in the United States and the District of

Columbia. The mission of the CHF is to provide compre-

hensive health care to the nation’s most medically

underserved children, from birth up to age 24. In-person

primary health care, mental health, and oral health services

are delivered by teams of doctors, nurses, dentists,

psychologists, social workers, and nutritionists at more

than 200 service sites across the United States in

partnership with pediatric departments and specialists in

affiliated academic medical centers or Federally Qualified

Health Centers (FQHC).

The CHF’s integrated approach to health care is

consistent with the concept of an “enhanced medical

home” in which continuity of care is ensured via coordina-

tion across multiple healthcare providers and specialties.

In the United States, the Medical Home concept is being

adopted as one aspect of health care reform to ensure a

high quality standard of care that also seeks to increase

efficiencies and reduce costs for acute care. This type of

integrated health care delivery is enabled by health infor-

mation technology (HIT)—not only computer software but

also communications networks.1

The cofounder and president of the CHF, Dr. Irwin

Redlener, received his M.D. from the University of Miami

in 1969. But his life mission for bringing medical care to

underserved children reportedly began when he was a

medical resident in pediatrics at the Children’s Hospital of

Denver and saw a poster for VISTA (Volunteers in Service

to America) with the words: “If you’re not part of the solu-

tion, you’re part of the problem.” Dr. Redlener’s quest to

become part of the solution began with delivering medical

care in Lee County, Arkansas, then working on earthquake

relief in Guatemala, followed by serving as medical direc-

tor for USA for Africa, and this poster is hanging in his

office today.2

An important motivation in my life has been work-

ing with kids whose situation makes them vulnerable

for reasons out of their control. They are desperately

ill, or living in extreme poverty, or disconnected

from medical care. I feel most energized by trying to

help children who have the fewest resources.

—Irwin Redlener3

In 1987, Redlener cofounded the Children’s Health Fund

(CHF) in New York City. Its initial focus was on pediatric

care for homeless kids, and his cofounder was singer/song-

writer Paul Simon. While working for USA for Africa, he

helped solicit the help of other recognized entertainers,

including Joan Baez, Harry Belafonte, Lionel Richie, and

Michael Jackson. When he learned that Paul Simon was

interested in doing something for the homeless, he reached

out to him:

I was working for USA for Africa, setting up the

grant office in New York City. Paul Simon, who was

on the We Are the World record, wanted to do some-

thing for the homeless. We visited a number of

welfare hotels. In the Hotel Martinique [in Times

Square] a thousand children and their families were

warehoused. Somebody suggested that we should get

a van and bring doctors there.

—Irwin Redlener4

That was the beginning of what would become CHF’s

national network of Children’s Health Projects (CHP), in

and Kevin Ryan, Distinguished Associate Professor, Stevens Institute of Technology.

1The Medical Home concept, which originated with the American Academy of Pediatrics in the 1960s, is today being considered as a means to reinvent primary care in the United States. One of the current barriers to implementation is the fee-for-service reimbursement model within the United States.

2As reported by Tom Callahan, “Mobilizing for Kids,” Diversion for Physicians at Leisure (April 15, 2004): 30–32. 3 Ibid. 4 Ibid. The “We Are the World” record was made to raise funds for the USA for Africa’s famine relief efforts. For example, see: http://www. inthe80s.com/weworld.shtml.

158 Part I • Information Technology

EXHIBIT 1 CHF National Network

other professionals in an RV-size mobile medical clinic

(MMC) that is driven to locations where the people are

who need it—such as city shelters for homeless families.

The flagship program with the first MMC was launched in

NYC in 1987, and by 2009 the program had been

expanded to cities and some deep rural areas within

CHF’s growing national network of clinics. The clinics

are supported by 41 state-of-the-art MMCs (32 medical, 3

mental health, 5 dental, 1 public health field office, and 1

health education) operating in different programs across

the country (see the map in Exhibit 1). By 2009, some had

been in service for many years and while not obsolete,

lacked some of the newest features, such as modular

network cabling and upgraded electrical generators; 7 new

MMCs were in some stage of procurement in June 2010.

The payments for the medical care provided by CHF

primarily come from four sources: private individual and

corporate donation, congressional aid, and two government

health insurance programs that support children living in

poverty. These programs are Medicaid and the State

Children’s Health Insurance Program (SCHIP). Medicaid

insures kids whose parents earn little or no money; the

federal government pays part of the costs, but programs are

administered and partially funded by state governments.

SCHIP, a newer federal program initiated in 1997, insures

children in families that earn too much to qualify for

Medicaid, but too little to afford private health insurance. In

February 2009, President Obama signed a bill that

continues funding for SCHIP ($32 billion over the next 4.5

years).

Mobile Medical Clinics at the Children’s

Health Fund

CHF’s Mobile Medical Clinics (MMCs) are housed in 36- to

44-foot long blue vans, designed to provide a full range of

pediatric primary health care including preventive care (e.g.,

childhood vaccinations), diagnosis and management of acute

and chronic diseases, mental health, dental, and health edu-

cation services. In addition to care provided in the mobile

clinics, care is provided at stationary clinical sites located in

shelters, schools, and community centers, and traditional

health clinics (e.g., the South Bronx Health Center for

Children & Families in NYC). The mobile clinics routinely

visit low-income neighborhoods and homeless and domestic

violence shelters to provide medical services, but MMCs

San Francisco Peninsula, CA

Los Angeles , CA

Idaho Montrose, CO

Arkansas

Chicago, IL

Philadelphia, PA

CHF National

Office, NY

New York City

Programs

Long Island , NY

New Jersey

Washington D.C.

West Virginia

Memphis, TN

Mississippi

Mississippi Gulf Coast

Orlando, FL

New Orleans, LA

Phoenix, AZ

Southern Arizona, AZ

Austin, TX

Dallas, TX

Children's Health Fund National Office

Children's Health Fund Programs

Affiliates–Special Initiatives

Baton Rouge, LA

South Florida

Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 159

have also been deployed to provide medical services in

response to public health crises or emergencies, including the

9/11 attacks on the World Trade Center, hurricanes Rita and

Katrina in 2005, and the 2010 Gulf of Mexico oil spill.

Two primary CHF principles are at the heart of the

design of the MMCs:

• To provide high-quality pediatric primary care as

well as mental health services, dental services, and

social services to medically underserved populations

with children.

• To operate in partnership with a high-quality local

medical institution, such as an academic medical

center or FQHC, to ensure access to other medical

experts as needed as well as coordinated health care

for the local population.

Access to reliable, affordable transportation is a major con-

straint for those living in poverty at government-sponsored

locations, as well as areas where there are few health care

providers, known as HPSAs (Health Professional Shortage

Areas). To help remove this constraint for low-income and

homeless residents in New York and four other major areas,

GlaxoSmithKlein provided a $2.3 million grant to support

transportation funding in 2004: $35,000 on taxi rides and

$20,000 on bus tickets for adults were spent by the Dallas

Children’s Health Project (CHP) the prior year. In New

York, this Referral Management Initiative had dramatic

results: specialist appointment compliance rose from 5 to

about 70 percent.5

The medical home concept is based on the premise

that a returning patient will be supported by a trusted

healthcare team who knows the patient and has access to

documentation of his or her health history. Exhibit 2

5 Tony Hartzel, “Transportation a Vital Health Link,” The Dallas Morning News (December 19, 2004).

EXHIBIT 2 The CHF Medical Mobile Unit (MMU) Model

160 Part I • Information Technology

shows a model of the MMC and its layout, with a separate

registration area and waiting room, a nurse’s station, and

examination rooms.

The sides of the blue vans are painted (like

“billboards”) to clearly signal that they are CHF units with

qualified medical personnel onboard. On a given day

during a given time period each week, the MMCs are

scheduled to be at the same location with the same medical

personnel onboard.

We don’t just show up like in an ice-cream man mode,

give a shot and disappear. The protocol is that every

Tuesday from X-time to Y-time the doctor is there.

—Jeb Weisman, CIO

Providing high-quality primary care from a mobile clinic

does present some unique challenges for supporting those

who are delivering the health care, such as:

• Designing an environment which is consistent with

and will support standard physician office and clinic

processes. This includes providing the required

space and medical equipment to support high quality

delivery of primary care, including sufficient, high-

quality electrical power.

• Complying with regulatory standards such as those

set forth by JCAHO (e.g., PC locations) and govern-

ment legislation (e.g., HIPAA laws for privacy and

security of personal health information).6

• Supporting a mobile unit that operates at multiple,

primarily urban, sites—each with its own unique

environmental factors.

• Providing computer and communications tech-

nologies within the MMC that are reliable and

dependable, as well as off-site access to technical

support.

Another important consideration is the overall cost for

each mobile clinic—including the initial costs for a state-

of-the-art MMC as well as continuing operating costs. The

majority of the approximately $500,000 capital budget for

each MMC is allocated to the required medical equipment

and associated vehicle requirements (i.e., space, power,

and transportation needs). Preventive care via a medical

home should of course result in long-term cost savings for

state and federal payers as children receive immunizations

and regular health checkups that can avoid costly visits

to hospital emergency rooms, but these are difficult to

measure. Given the national shortage in primary care

physicians, CHF’s association with a major medical center

also means that MMC may be part of medical residents’

formal training rotation, often in pediatrics or community

medicine, as part of the medical team.

Healthcare Information Systems

to Support Primary Care

In the United States today, it is still not unusual to find

paper-based record keeping in physician practices (referred

to as ambulatory or outpatient practices). Two types of

functionality are provided in software packages developed

and maintained by vendors who specialize in the healthcare

industry:

• Practice Management Systems (PMS) support

administrative tasks such as patient workflow and

the revenue cycle, with data including patient con-

tact information, appointment scheduling, and

patient insurance plan information.

• Electronic Medical Record (EMR) systems support

clinicians, such as patient diagnosis, treatment and

physician orders, with data including patient demo-

graphics (age, gender), family history information,

allergies, medications, and clinical documentation of

diagnoses, treatments, and outcomes for prior visits

and specialty referrals.

By 2008, only 4 percent of physicians in ambulatory settings

had a fully functional EMR; 13 percent had a partially

functional EMR; but 50 percent of those in larger practices

(11 or more physicians) had partial or full EMR support.7

Some vendors provide packaged solutions with PMS

and EMR modules designed to exchange data with each other.

However, since some of the clinical packages are designed to

specifically support certain types of care—such as pediatrics,

OB/GYN, cardiac care, and so on—specialty practices in

particular may have purchased software from different

vendors. In addition, software that supports electronic

prescription transactions to pharmacies and insurers has

recently been widely adopted as this capability has become

required for reimbursements by government and other

insurers. Investments in software packages to support clinical

processes in small practices (1–3 physicians) in particular will

be made at a much faster rate during the second decade of this

century due to financial incentives administered by Medicaid

and Medicare to eligible physicians who have implemented 6JCHAO (Joint Commission on Accreditation of Healthcare Organizations) is the accreditation body for healthcare organizations. The HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule governs all protected health information; the HIPAA Security Rule sets security standards for protected health information maintained or transmitted in electronic form.

7 2007 study by the Institute of Health Policy at Massachusetts General Hospital (MGH).

Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 161

certified electronic health record systems and reported specific

metrics for Meaningful Use beginning in 2011 under the

HITECH Act.8

The advantages of using computerized health infor-

mation systems were recognized early on by the CHF. Jeb

Weisman, the current CIO, initially joined the organization

in the late 1980s prior to the implementation of the first

MMC to lead the efforts to provide state-of-the-art support

for the MMCs. Initially a home-grown system was devel-

oped and maintained.

Given the way the transitional housing system for the

homeless worked at the time—there were enforced

moves every 3 weeks and that sort of thing—it was

incredibly important that you had a real history.

Some of these kids were being immunized half a

dozen times for measles, by the time they were 6 or 7

because if something would show up, it is better to

give them shots than not . . . . So you had as much as

medical over-neglect as under-neglect going on.

Records are vitally important.

—Jeb Weisman

In 1999, CHF partnered with a now defunct vendor to

develop specialized technology for the MMC environment.

This system was then phased out in 2007 when CHF part-

nered with another leading Electronic Health Record

(EHR) software vendor: eClinicalWorks.9 Given the CHF’s

early investment in custom software that supported the data

collection of detailed clinical data specifically for pediatric

care, Weisman’s team built in a similar data collection

capability for use with the commercial software package.

Having this detailed information in a standard format

enables high-quality patient–physician interactions on not

only the first but also subsequent visits, in addition to pro-

viding the data needed for referrals. Medically underserved

populations typically have higher levels of lead in their

bloodstreams, asthma, and other chronic conditions.10

One of the record keeping challenges faced by all

physician practices is the integration of laboratory and

imaging results with the rest of a patient’s health record.

In a paper environment, the test results are typically faxed

from the facilities performing and interpreting the tests to

the requesting physician, and then paper copies and film

(such as x-rays or CAT scans) are filed in the patient’s

folder along with other hard-copy records. When test

results are not received in a timely manner, a nurse or other

staff member typically makes a call to the test facility’s

staff and can receive the missing record in a relatively short

time period. Today’s more sophisticated healthcare

information system (HIS) solutions integrate electronic

reports of test results with the patient’s record so that the

physician can quickly access all relevant data with the

same patient record interface.

However, maintaining an accurate medical history

for a patient who lives in poverty and may be residing in a

homeless shelter or other temporary housing is more com-

plicated than for patients with a more permanent address.

In cities and towns with CHF clinics, a patient served by a

specific clinic in a given neighborhood in the Bronx this

month may be domiciled in a different shelter in a different

borough and show up at a permanent clinic or MMC in a

different location in NYC the next month. To retrieve a

record from another clinic may require a phone call and

fax capabilities.

Both telephone and fax capabilities are therefore basic

requirements for not only retrieving missing data but also

consulting with other medical experts, and supporting pa-

tient referrals to other clinicians, including specialists. An

ideal solution to capture the patient data that have previous-

ly been collected for the same patient—especially when the

same software package is being used at multiple clinics—

would be to have it available in structured electronic form.

Connectivity Needs to Support Mobile

Medical Clinics

There are therefore two primary communications needs

for clinicians to deliver quality healthcare via a mobile

clinic: (1) access to patient data previously captured at

another medical facility (or MMC) but not yet available in

the patient record system in the clinic and (2) access to

personnel at another medical facility for either an emer-

gency consult or referral, or a more routine referral. In an

ideal world, all of the network requirements described

below for a mobile clinic environment would be satisfied.

However, some unique challenges are associated with

MMC service environments.

• Network availability and reliability. The number 1

networking requirement is that remote access to data

and people needs to be available. Yet the MMCs are

deployed mostly in dense urban areas—and some-

times in sparsely populated rural areas—that may

8 The implementation of an HITECH Act, which is a portion of the American Recovery and Reinvestment Act legislation signed into law by President Obama in February 2009, is overseen by the Office of the National Coordinator for HIT within the U.S. Department of Health and Human Services. An EHR is similar to an EMR, except it is designed to exchange data with other healthcare systems external to the healthcare provider who owns it. 9 Soon after this adoption date, eClinicalWorks was selected as an EHR

vendor for the New York City Department of Health and Mental

Hygiene’s (DoHMH) Primary Care Information Project (PCIP). 10 As reported in an interview of Irwin Redlener by Janice Lloyd, “‘Kids Can’t Wait’ for Health Care,” USA Today (May 21, 2009): 7D.

162 Part I • Information Technology

not provide network availability or may not provide

reliable access to voice and data networks.

• Data security. At a minimum, HIPAA requirements

for data security must be met. User data must be

encrypted at the database server level, and additional

encryption and “network tunneling” are needed for

protection of patient data at the network level.11

• Easy to use with zero on-site support.

Networking technologies in the MMCs are there

to support the high-quality delivery of pediatric

primary care. Since the highly trained and educated

medical staff is not necessarily sophisticated in

knowledge about networking technology and

maintenance of equipment, it is critical for the net-

working solution to be “push-button” technology

and require little infield maintenance and

provisioning.

• Inexpensive to deploy and operate. The installed

networking equipment should not add significant

expense to the cost of an MMC. The network solu-

tions should also be readily available and easy to

acquire plus easy to install in the MMC.

• Network throughput (data rate) and latency.

The data rate must support the transfer of text-

based files (medical health records and patient

referrals). The transmission of high-density med-

ical images (e.g., digital X-rays) requires much

higher throughput rates and therefore provides a

different challenge. Another critical requirement

is to minimize network latency; large latency

results in inefficiencies and possible confusion on

the part of the MMC staff (e.g., “Is the network

connection still active or not? Why is it taking so

long to load?”).

Connectivity Solutions: What Worked

and What Didn’t

Since the launch of the first MMC in the 1987, several

networking solutions have been tried and newer technolo-

gies have become available and affordable. Two different

wireless network solutions were tried, with mixed results.

Satellite-Based Access

In 2005, a number of MMCs were equipped with

rooftop-mounted satellite antenna systems. These antenna

systems were equipped with a setup function which

automatically unfolds the antenna and raises the antenna

from a horizontal (“flat”) position to a position where the

antenna is facing the sky. The antenna then performs a

scanning operation to detect the strongest available satellite

signal and begins establishing a communications link with

the satellite. When the system is powered down, the antenna

folds back into the original horizontal position. Although

these systems were expensive and designed for mobile

operation, they proved to be mechanically unreliable.

You have these structural limitations to the system.

Every day it goes up and down but unlike mom-and-

pop casual use, we’re dealing with vital health care

information and communications. Invariably, the

mechanical system breaks down—a gear strips, a

connector fails, or a circuit fries. We have had doc-

tors and nurses climbing on the roof to manually

lower the antenna system, and these are high-end,

sophisticated devices . . . . Well, that is not good on

many levels, not the least of which alienates users

towards the technology.

—Jeb Weisman

They also posed structural problems for the MMCs (due to

their weight). In some situations, the satellite communica-

tions also had unacceptably large latency due to the nature

and design of satellite communication systems.

It is interesting how expectations get managed in

these kinds of environments. In terms of throughput or

capacity in a perfect world, most of the data that you

are moving is simple structured textual data. So actu-

ally you need very little bandwidth, but you need

bandwidth without significant latency . . . . A 1.5

Megabit satellite connection is way different from 1.5

Megabit connections on a wired line or even in

Wimax, or whatever the flavor of the month is, in a

traditional Ethernet-based system. The latency is a

killer. It is deceptive for the end user: even if the

throughput is okay to move that image down, or to

move those data up, they don’t trust it—because it

takes longer to refresh than we are used to today at

home or in the office. Do they step away and hope

their data are refreshed when they are taking care of

the patient, or do they stand there for twice as long

waiting for something to happen? Very often wireless

communication at the satellite level can make things

worse than just going with the flow—which is to say

‘we are here, we are in a box in the middle of

nowhere, and we just have got to manually write it

down and deal with it later.’

—Jeb Weisman

11 Tunneling is a networking technique that encrypts user data for secure transport over the public Internet.

Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 163

Cellular Wireless Networks—Wireless

Modem Solution

First piloted in 2004 and formally entered into service in

2007, the MMC was equipped with a Sierra Wireless

AirLink PinPoint X wireless modem that provided Third

Generation (3G) wireless service with a “fall-back” capa-

bility to 2.5G wireless service in areas where 3G service

was not available. The advantage of this specific wireless

modem was that it supported both 3G standards widely

deployed in the United States: both Universal Mobile

Telecommunications Service (UMTS) and cdma2000. The

potential for 3G rates is in the range of several Mbps, so

this wireless solution provided the MMC with a high data

rate to and from the Internet. However, the transmission of

patient data requires cellular coverage and reliability at a

“mission-critical” or “professional” level, but today’s gen-

eral purpose wireless networks are designed for “con-

sumer” levels. If the wireless coverage is not available and

reliable, this solution can only be used to support MMC

communications that are not mission critical.

For the clinicians working in the mobile clinics,

dependable and predictable wireless access to the Internet

is more critical than achieving higher data rates. 3G and

the emerging 4G networks do have the required throughput

(4G wireless networks are promising 100 Mbps) for trans-

mitting more than text-based data. However, what these

networks do not deliver is reliable and dependable cover-

age (i.e., network access) at the level required.

A hybrid alternative that has been tried is to delay

data transmission from the MMC until there is access from

the van to a wired broadband solution, such as in a commu-

nity center or school.

Delayed Broadband Wired Access

In this mode of operation, the MMC operates as a “store-

and-forward” device: patient records, medical referrals, and

digital images are stored on an MMC server until wired

broadband Internet access is available. A typical configura-

tion is to have a wireless LAN (WiFi) connection via a

wireless router from the MMC to the broadband access

point into the other facility. The obvious disadvantages of

this approach are the delay in accessing and transferring

information, and the security of the wireless LAN link. In

addition, the MMC is not always able to use a nearby third-

party’s wired network due to local restrictions on access

to its wired broadband connection or HIPAA security

concerns.

Many of these organizations or institutions, particu-

larly ones that are city based, won’t allow you to

install your own telecom infrastructure in their build-

ings. So we can go to shelters where they even often

have an Internet or network-based infrastructure and

we are not allowed to connect to it. Plus then we have

some problems around what I will generically refer to

as a HIPAA Issue–we can’t just go through any old

network . . . HIPAA rules are actually changing sub-

stantially—becoming much more restrictive, much

better prescribed and set out, and much more painful

if you violate them . . . . So when we look at the solu-

tions, we have to make sure we can tunnel.

—Jeb Weisman

Asynchronous Multi-Master Database

Replication (AMMR)

In the absence of a reliable, high-speed networking solu-

tion to enable patient data transfers from the MMCs to the

central server at the headquarters of the New York CHP in

the Bronx, a more hands-on solution has been adopted to

enable (1) the integration of patient record data collected at

multiple sites and (2) provide a backup capability. But it

also requires physical proximity of the servers in the

MMCs to the CHP offices.

Banks figured out years ago that if you could put a

teller machine in a town in Montana, people would use

it and you would make money on every transaction.

But do you think there was telecommunications out to

that town? There was not. So how did it work? AMMR.

At some point the cash machine could dial up in the

middle of the night, when rates were low, and send the

data up to Wells Fargo. It all got merged together, busi-

ness rules were applied, and then it sent back down

inserts to the [ATM] database. [The ATM] knows what

it needs to know and makes it through another day,

without real-time high bandwidth telecom.

What happens here is that all the servers from

the vans are physically brought in to a central loca-

tion so that there are X number of what we call the

laptop servers connected to the master or primary

server. We press the button and it goes through a

kind of round robin, moves the data up to the master

from each one, applies business rules, aggregates the

data, and then copies the identical data set to every

single one of those [servers]. We do it through

inserts; we are not actually copying 10 gigs of data

down to each one, so it is a very efficient process.

And when you are done, each one of those devices is

an exact working copy of the entire data set. It’s an

elegant solution to an inelegant problem.

—Jeb Weisman

164 Part I • Information Technology