To anticipate the future, take a look at the past. It makes particular sense in health care when critical decisions are based on patients' medical history. However, for foster children who arrive at new homes with few or no treatment records, knowing the past poses a major challenge. Documented allergies, immunizations and illnesses are often shrouded in mystery when foster parents welcome a child.
That changed for Texas foster children April 1, when the state Health and Human Services Commission (HHSC) rolled out the online Health Passport. Today more than 30,000 foster children have electronic records that update most information automatically and follow children when they move to a new home.
The Health Passport, one feature in an overhaul of the Texas foster child health-care system, is the latest program in a larger trend toward electronic health records. It's the first program of its kind in the country, but project developers say other states may soon follow Texas' lead.
From insurance claims to food allergies, a foster child's medical data is housed by an array of companies, state agencies and practitioners. The Texas Health Passport draws these data sources together and presents them side by side. Through a Web-based interface, each child's guardian, doctors and "medical consenter" (a legal designation often, but not necessarily, awarded to the foster parent) can access the passport, review the child's medical history and make necessary updates. Meanwhile, insurance claims, lab results and most other medical data update automatically. The result is a more complete and accurate snapshot of the child's medical history.
Rooted in Negotiation
The Health Passport is rooted in SB 6 from the 2005 state Legislature. The bill is loaded with measures to improve programs under the state's Department of Family and Protective Services (DFPS). The bill included a mandate that foster children's health care be streamlined under a single management program. It also contained a "Medical Passport" section covering information the electronic passport should contain. Once the bill passed, the HHSC held sessions with the DFPS, foster care providers, advocacy groups, health-care providers and technology companies, to draw up a blueprint of the passport.
Yvonne Sanchez, senior health policy analyst of the HHSC, said the Health Passport that's online today is the product of a long negotiation among all stakeholders. "Those were really intense sessions because we have two different agencies, different providers. Everyone has different needs, different things they wanted to get out of the Health Passport," Sanchez said. "Ultimately we were just steering the process, trying to come up with a design and a model that would really work to benefit the users."
Texas received a $4 million federal grant from the U.S. Department of Health and Human Services to build the system, as part of a larger push to advance health-care IT countrywide. In March 2007, the HHSC awarded the blanket contract for foster child health-care management to Superior HealthPlan, operated by St. Louis-based Centene Corp. The management solutions that Superior developed under the contract, including the Health Passport, formed a new program called Star Health.
Superior's Health Passport program manager, Sloane Cody, said there was a short learning curve because the company was already managing parts of Texas' Medicaid and Children's Health Insurance programs. "We're lucky - we had worked with a lot of the vendors before and had a relationship with the community we cover in Texas," said Cody. "We were lucky that SB 6 gave a fair amount of detail and the contract we went into offered a lot of detail."
To build the passport, Superior assembled groups of four or five full-time staff members to handle specific project areas: data interface management, access security, integrating whole assessment forms and reports, demographics, and integrating the child's and caregiver's personal information. To build the framework technology, Superior contracted with Cerner Corp.,
a Kansas City, Mo.-based health IT provider whose Tennessee Medicaid management system became a model for the Texas Health Passport.
Cody said the biggest challenges Superior faced were data interface management and handling transactions between the passport and the 12 medical data sources. Superior's data warehouse and experience with similar problems were key to building the system. "It took a lot of design sessions," Cody said, "but we're lucky we were able to leverage a lot of processes and exchange methods we already had in place."
The display for each passport begins on a demographics page that displays basic personal data, such as name and date of birth. Crucial for foster children, it also includes listings for medical contacts, such as physicians, guardians, caseworkers and medical consenters. "This is one way we can clearly document who is involved with these children's lives across the board," Cody said. "It's really a good way to be sure those behavioral health and physical health providers know their counterparts. That's one piece that's unique."
A foster child may also have state-required assessment forms in areas such as behavior and dental health. Each child's Health Passport includes a screen listing the assessment forms, which give detailed information doctors can't glean from other areas of the system. Medicaid claims, immunization records, prescriptions filled, office visits, lab results and vital signs - such as height, weight and blood pressure - are all additional passport modules.
Passport Security Addressed
Controlling access to the passports was another major undertaking, Cody said. Superior recognized that as children move from one home and set of guardians and doctors to another, it becomes difficult to secure front-end access.
Front-end system security is handled by a login process with a unique PIN. The DFPS gives each authorized individual a unique identifier, and larger providers are allotted a certain number of staff members who can access the Health Passport.
Another step in the security-building process was to assign various access levels to 19 distinct user roles, to keep, for example, foster parents from changing data on a child's office visit history. Each time users log into the system, Cody said, their identity is checked against Superior's daily updated list of people who have access to the system. All that is just to log on to Superior's secure, private site - users must supply another login and password to reach the passport itself.
Cody said the security measures comply with the Health Insurance Portability and Accountability Act, which requires discretion when handling patient health records - whether physical or electronic. Normally an individual must sign off on every release of their medical information, but Cody said because the DFPS is legally responsible for all Texas foster children, the department is responsible for access to the Health Passport.
In addition, Superior and the HHSC track usage and flag unusual activity. "I have staff fully dedicated to auditing and doing security measures, and we send the HHSC weekly and daily reports on usage," Cody said. Superior has guidelines for normal activity on the system and checks the actual usage against them. "Our criteria set for that is actually pretty low, so we haven't had any breaches that turned out to be real," Cody said.
The Health Passport came online stocked with two years of insurance claims and medical data for more than 30,000 foster children. Officials said problems have been minor and were to be expected. "We've had a really successful implementation," said Marisa Luera, project manager of the HHSC. "Providers, in particular, are pleased with it because before, when children moved, we really didn't have any medical history. The Health Passport does that with two years of claims data to start with."
At the Center for Public Policy Priorities, an Austin, Texas-based nonprofit policy watchdog, Policy Analyst Stacey Pogue said they're "cautiously optimistic" about the Health Passport. Access and security issues are potential concerns, she said, if they aren't flagged by Superior's usage reports. In addition, while state records feed most of the data automatically, some inputs - including allergies and vital signs - must be manually entered, which makes it possible they'll be incomplete. "Hopefully providers have someone entering it every time they discover an allergy, but it does take some time to enter those," Pogue said. "Even if they don't, it's a lot better than what they had before. I think it will be a really great tool."
While the HHSC studies passport-user satisfaction, it'll also be preparing a report for the Texas Legislature on the feasibility of expanding the program to all Medicaid users. Some of the Health Passport's features are unique to foster children - i.e., information about caseworkers and some health assessment forms - but most of the medical data would be the same. "The application itself, and the platform it resides on, could certainly support a lot more end-users," Cody said. "The challenge there would be multiplying by 100 times the number of different information sources."
The HHSC's Sanchez said a number of states are looking at electronic health records driven by medical claims, though none have implemented a system for foster children like Texas. Cody said Superior's parent company, Centene Corp., is looking into adapting Texas' Health Passport to its second-largest network, Georgia's Peach State Health Plan.
"There is no other Health Passport like this in the U.S. at this point. We were the first ones to do something of this scale for an entire Medicaid population," Cody said.