FY25 HCCN Objectives and Sample Activities

• Using data management and analytics to help use value-based care models.
• Providing customized data management and analytics support to PHCs, as identified on their individual work plan. 
• Facilitating workshops on data analysis or data visualization.
• Developing and using data management governance framework.
• Supporting coding accuracy and clinical risk-stratification capabilities.

2. Interoperability and Data Sharing – Increase the percentage of PHCs that optimize bidirectional interoperability with health care providers and community-based organizations by:

• Strengthening care coordination
• Reducing unnecessary medical testing and data duplication
• Using more efficient and effective referral and information sharing processes to improve health outcomes and reduce provider burden
   

• Helping PHCs connect to a Qualified Health Information Network (QHIN) to share data with other healthcare providers.
• Creating or connecting to QHIN. 
• Developing, using, and optimizing closed-loop referral systems with other health providers or community-based organizations through an electronic health system.
• Using Fast Healthcare Interoperability Resources (FHIR) to automate clinical quality and other types of reporting.
   

• Participating in HRSA’s UDS+ readiness activities to support PHCs in submitting high quality UDS+ data. 
• Using UDS+ readiness assessment results to improve health center data submissions.
• Collecting and sharing PHC feedback on testing challenges, data/system outcomes, and other issues with EHR vendors.
• Talking with EHR vendors to identify and address PHC concerns regarding data quality, system/data improvement or enhancements, data requirement changes, etc.
   

• Assessing readiness and barriers to data sharing, management, and analysis. 
• Teaching and explaining risk adjustment methodologies that payers use.
• Holding forums with EHR providers (vendors) on optimizing EMR for value-based care clinical practice.
• Supporting efforts to better understand patient population attribution.
• Regularly using data analytics to inform and update PHC clinical and operational workflows. 
• Using data-driven insights to decide how best to manage and report finances.  
• Using data and patient attribution to prepare for payer contract negotiations.

• Training health care workforce and patients to use digital health tools to develop the workforce and improve patient health outcomes. 
• Monitoring whether digital health tools are effective for PHCs. Include reasons why some may not use or comply. 
• Developing patient education programs on digital health literacy.
   

• Responding to emerging cybersecurity threats by developing manual workflows to support PHCs during an active cybersecurity attack. 
• Expanding network partnerships to include those with expertise and focus on cybersecurity.
• Complying with new and existing state cybersecurity regulations.
• Conducting training on techniques such as:
  
  1. Multi-factor authentication (MFA)    
  2. Encryption Intrusion detection systems (IDS)
  3. Regular security audits     
  4. Staff training programs on cybersecurity awareness  
  5. Tabletop exercises 

• Developing an AI-ready workforce and culture.
• Identifying gaps and unmet needs in health and scientific areas that would benefit from the use of AI.
• Developing a monitoring system to ensure integrity of patient data.
• Using transcription services or automated referral systems.
• Improving AI clinical models.
• Developing standards on how to use AI across PHCs using the same EHR.

• Connecting patients with employment training. 
• Using tools to connect patients with financial help, food pantries, housing, transportation resources, legal, or educational services.
• Integrating population health screening tools in clinical workflows and managing associated data.