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APPENDIX J

6100036706

New Data System for Healthy Woman, WISE WOMAN, and Colorectal Cancer Screening Program Requirements Document

Table of Contents

1 Purpose of the Document 3

2 Acronyms 4

3 Executive Summary 6

4 Introduction 7

4.1 Project Overview 7

5 Business Model 8

5.1.1 Organizational Profile 13

5.1.2 High Level ‘As-is’ Process Flow 14

5.1.3 High Level ‘To-Be’ Process Flow 41

5.1.4 Process Mapping 43

6 Requirements Definition 47

6.1 Overview 47

6.1.1 Approach 47

6.2 Detailed Requirements 47

6.2.1 High Level Business and System Requirements 47

7 Addendum 48

8 Glossary of Terms 50

Purpose of the Document

The purpose of the Requirements Document (RD) is to lay the foundation for the design and development of a technical solution. The RD describes the high-level business process and also outlines the business needs that will be fulfilled by the successful completion of the project and also takes this one step further and identifies actual technical or system requirements for the solution.

The foundation for a successful project is built upon the quality and thoroughness of requirements gathering. The RD establishes key requirements, objectives, and goals that drive all other subsequent lifecycle phases. It describes the business problem to be solved in terms of verifiable and traceable characteristics and constraints. In addition to key program level requirements, the RD also captures operational concepts and program level interfaces. This document should be continuously referenced during the project lifecycle phases to ensure that the deliverables from the project meet the approved requirements.

Acronyms

Table: Acronyms Used in This Document

|Acronym |Definition |

|ABCS |Aspirin and A1C, Blood Pressure Control, Cholesterol Management, Smoking Cessation |

|ASCCP |American Society for Colposcopy and Cervical Pathology |

|BCC |Breast and Cervical Cancer |

|BCCPT |Breast and Cervical Cancer Prevention and Treatment Program |

|BMI |Body Mass Index |

|BP+ |BP+ CDC Visit type |

|CBE |Clinical Breast Exam |

|CCDE |Colorectal Cancer Clinical Data Elements |

|CDC |Centers for Disease Control |

|CPT |Current Procedure Terminology |

|CPPI |Core Program Performance Indicators |

|CRCCP |Colorectal Cancer Control Program |

|EHC |Extended Health Coaching |

|EHR |Electronic Health Records |

|FHCCP |Family Health Council of Central Pennsylvania, Inc. |

|FIT |Fecal Immunochemical Test |

|FNAB |Fine Needle Aspiration Biopsy |

|FOBT |Fecal Occult Blood Test |

|FPIG |Federal Poverty Income Guidelines; established annually |

|HBP |High Blood Pressure |

|HC |Health Coaching |

|HDL |High Density Lipoprotein |

|HITECH |Health Information Technology for Economic and Clinical Health |

|HIPAA |Health Insurance Portability and Accountability Act |

|HMO |Health Maintenance Organization |

|HPV |Human Papillomavirus |

|HW |Healthy Woman |

|IVSF |Intake Visit and Summary Form |

|LDL |Low Density Lipoprotein |

|LEEP |Loop Electrosurgical Excision Procedure |

|LGBTQ |Lesbian, Gay, Bi-Sexual, Trans-Sexual and Questioning |

|LSI |Life Style Intervention |

|LSIL |Low Grade Squamous Intraepithelial Lesion |

|LSP |Lifestyle Program |

|MA |Medical Assistance or Medicaid |

|MDE |Minimum Data Elements |

|MFHS |Maternal and Family Health Services |

|NBCCEDP |National Breast and Cervical Cancer Early Detection Program |

|PA DOH/ DOH |Pennsylvania Department of Health |

|PN |Patient Navigator |

|QA/QI |Quality Assurance/Quality Improvement |

|RPM |Regional Program Manager |

|TLC |Therapeutic lifestyle changes |

|USPSTF |United States Prevention Services Task Force |

|WHR |Waist to Hip Ratio |

|WISEWOMAN |Well-Integrated Screening and Evaluation for Women Across the Nation |

Executive Summary

Currently the Healthy Woman (HW) and WISEWOMAN program data are managed in one data management system and the Colorectal Cancer Control Program (CRCCP) data is managed in a separate data management system. However, it is more desirable to have one integrated data management system that can store and process the data from all three program areas. Toward this end, the Division of Cancer Prevention & Control and Division of Health Risk Reduction have opted to implement a web based Commercial Off-The-Shelf (COTS), Modifiable Off-The-Shelf (MOTS) or Software as a Solution (SaaS) product as a business solution.

In the effort of documenting requirements, multiple interviews were conducted with the program team members who use the system extensively. A Business Analyst (BA) along with HW project team members have conducted interviews with the contractors who use these systems on a daily basis to achieve an understanding of the as-is business processes. Both of the existing systems were analyzed (i.e. the data system used for WISEWOMAN and HW programs and the data system that is used for CRCCP program) to acquire adequate knowledge of the data that is required to be captured and stored. Once a thorough understanding of the current business process was gained, the as-is process was documented. The as-is process was later verified with the program team for accuracy. After the as-is process was completed, multiple one-on-one brainstorming sessions and multiple JAD sessions were conducted with program team members. Questionnaires were sent to the contractor to get an understanding of the end user needs. The To-Be flow was then documented completely. After the as-is and to-be flows were documented, the gap analysis was conducted, and based on the user needs the business requirements and system requirements were created.

The new system will serve as a reliable and integrated web based data management solution for HW, WISEWOMAN and CRCC program users. The most significant impact will be for both internal and external users. Internal users can heavily rely on the system for reporting purposes, generating multiple reports to be used for decision making, reimbursements, program improvement, statistics, state and federal reporting (CDC), and quality assurance of the provider sites. The HW and CRCCP program teams can rely on the system for merging the cancer registry data with the DOH data. The external users will be highly benefited with reporting services, provider/clinical staff can rely on the report data for the follow up activity. Also the new system will reduce the repetitive data entry by structuring the form layouts in the data system.

The new integrated data system will serve as a business solution for HW, WISEWOMAN and CRCCP users while maintaining the performance efficiency, HIPAA /HITECH compliance and data integrity.

Introduction

1 Project Overview

Currently the HealthyWoman/WISEWOMAN Program and Colorectal Cancer Control Program data are maintained in two different systems. PADOH is looking for a new, dynamic, comprehensive, stable and integrated, web-based application that can be used by HW, WISEWOMAN and CRCCP users. The potential users of the new system will be DOH, contractors, sub-contractors and providers. The new system is intended to have capability to handle HW, WISEWOMAN and CRCCP client and provider data. The system shall provide the capability for the DOH users to generate the Minimum Data Elements extracts of HealthyWoman (HW), WISEWOMAN programs and Colorectal Cancer Clinical Data Elements extract of Colorectal Cancer Control Program (CRCCP) as needed. DOH users shall also have the capability of creating on demand reports and queries as well as complete system extracts. Other than the above mentioned functionalities, the new system is intended to perform various program driven and user defined functionalities. The details of each required functionality are defined in the Detailed Requirements section of this document.

Business Model

Healthy Woman Program:

HW is a program that is responsible for early screening and prevention of Breast and Cervical cancer in Woman in Pennsylvania. In 1990, the U.S. Congress recognized the lifesaving potential offered through early detection when it passed The Breast and Cervical Cancer Mortality Prevention Act (P.L. 101-354, 42 U.S.C. Section 300k, et.seq.). The Centers for Disease Control and Prevention (CDC) administers the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) created by the 1990 legislation. In 1993, the Pennsylvania Department of Health (Department) entered into a cooperative agreement with the CDC to implement a comprehensive breast and cervical cancer early detection program for women 50 to 64 years of age. In 2005, Act 74 authorized state funds to screen women ages 40-49; this has been incorporated into the HealthyWoman Program (HW).

The state contracts with one grantee who in turn subcontracts with service provider sites for mammograms, Pap tests, and other required services.

The HW program provides low-income, uninsured and underinsured women access to timely breast and cervical cancer screening and diagnostic services. The vision of the HW program is to eliminate the burden of breast and cervical cancer.

Eligibility of a woman to enroll in the HW program is determined based on three self-declared issues: (1) age and residency; (2) income/family size; and (3) insurance status. Please refer to HW Eligibility-At -A-Glance table below.

The HealthyWoman program provides free Breast and Cervical screening for eligible clients across Pennsylvania.

The following table depicts the HW eligibility at a glance:

|Pennsylvania Free Breast and Cervical Cancer Services |

|Eligibility-At-A-Glance |

|Age |

|Under 40 |Eligible if symptomatic |

|40-49 |Eligible |

|50-64 |Eligible |

|65+ |Eligible if not covered by Medicare Part B |

|Citizenship/PA Residency |

|U.S. Citizen or Qualified Alien |Eligible (self-reported); can enroll regardless of |

| |response |

|PA Resident |Required for eligibility; self-reported |

|Social Security # |Not required |

|Income |

|Income |Eligible (self-reported – Under 250% of Federal |

| |Poverty Income Guidelines) |

|Insurance |

|Uninsured |Eligible (self-reported) |

|Credible Insurance |Eligible under certain circumstances |

| |(self-reported) |

|Underinsured |Eligible (self-reported) |

|Other |

|Other Required Documentation |HW Consent & Enrollment Form |

Table 1: HW eligibility at a glance

HealthyWoman program area is responsible for:

• Providing breast and cervical screening and diagnostic services to eligible clients.

• Monitoring any abnormal results

• Monitoring follow up activity for abnormal results

• Monitoring referrals to BCCPT program

• Monitoring lost to follow up activity

• Meeting the CPPI measure percentage values

• Sending the MDE extracts to CDC twice a year

To provide the HW services, currently DOH contracts with ‘The Alliance of Pennsylvania Councils, Inc.’ which in turn contracts with 4 major contractors and other sub-contractors. Each of the contractors is responsible for monitoring the services provided by their provider groups and for releasing funds based on the provided services. Each provider site is responsible for capturing and maintaining the clients’ demographic information, the clients’ health information, and the services provided. Based on the services provided, the appropriate details are captured in the data system.

The CDC has endorsed the use of the California Breast Cancer Diagnostic Algorithms guidelines, released in June 2011; these guidelines have been adopted by the PA DOH for use in the HW program. The California Breast Algorithms provide the follow-up protocols and timelines. As per the timeline guidelines, if the CBE results are abnormal, the results have to be recorded in the IVSF and the additional diagnostic testing must be completed within 60 days. The client has to be notified of the abnormal results within a 30 day time period. Clients who are diagnosed with breast cancer have to be referred to the BCCPT program and the treatment of clients diagnosed with breast cancer must begin within 60 calendar days of the final diagnosis. The referral has to be tracked in the data system. Based on certain types of mammogram results, the client has to be scheduled for re-screening at 6 months. For example, if the outcome of the mammogram is ‘Category III – Probably Benign,’ the client has to be scheduled for re-screen at 6 months and the follow up activity has to be marked in the data system. The completion of the final diagnosis must be within 60 days or less from the first abnormal results to be in compliance with the CPPI.

For the cervical screening, the ‘American Society for Colposcopy and Cervical Pathology (ASCCP) ‘consensus guidelines, released in 2012, have been formally adopted for use as the standard guidelines for the NBCCEDP. The results are reported using Bethesda (2001) terminology. Results of Pelvic Exam and Pap test must be documented in the woman’s medical record and IVSF within 30 days of the service. Schedule any additional testing/visit for the woman that day or follow-up in 5 calendar days to confirm appointment. For example, if the outcome of the Pap test result is ‘Low Grade SIL (including HPV changes),’ the client has to be scheduled for the 6 month re-pap, HPV test, or colposcopy. For the diagnostic options, the 2012 ASCCP Algorithms (cytology and histological) contain the follow-up protocol and timelines. If abnormal screenings result, the time from screening to diagnosis must be within 90 calendar days or less to be in compliance with performance indicators.

It is important that there be a means to ensure timely contact with the client for reporting results and scheduling follow-up services. The Providers/ clinic staff are responsible for the follow ups and scheduling of the screenings. The current system does not contain automated alerts based on the abnormal results or the scheduled screening dates, but does generate a report that lists clients who are scheduled for follow up.

All services reported on the IVSF are to be reported to the woman within 30 days of service and are to be entered into the web-based data system within 45 days of the service to be eligible for data entry payment. The provider site is responsible for reporting all the services provided to the HW clients in the DOH designated data system. Entry of data must be made within 45 days of services performed and has to be electronically submitted to DOH via data system; failing to perform this activity will lead to not receiving payments for the data entry and management cost. The data needs to be submitted to DOH electronically no later than 90 days from the date on which the services were performed. The current system does not have any functionality to alert the users regarding the pending IVSF and Diagnostic forms in the data system.

The data on HW clients who are diagnosed with cancer is sent to the cancer registry each year. The cancer registry department performs the match and sends back the matched client records with additional fields. The DOH user has to manually verify the match and link the client data. There is no way to save the additional data or to link the records in the existing data system. These cancer registry fields are part of the MDE extract, so it is important to have a system that can handle importing of the registry data and linking to the HW client data with minimal user intervention.

WISEWOMAN Program:

In 1993, the CDC funded the Well Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) Program to provide cardiovascular screenings and lifestyle interventions to clients enrolled in a state’s National Breast and Cervical Cancer Early Detection Program. WISEWOMAN was authorized through the same act as the HWP, with additional legislation in H.R. 3288 providing for additional resources and guidance. Pennsylvania applied and was initially funded in the 2008 - 2009 fiscal year and continues as one of 21 CDC funded WISEWOMAN programs.

A woman is eligible to enroll in to the WISEWOMAN program if she meets income, insurance, and other HWP guidance in order to be eligible for HWP services or has been navigated by the HWP. Currently, clients meeting the guidelines of the HW program or clients meeting the clinical protocols and between the ages of 40‐64 are eligible to enroll in WISEWOMAN at designated provider sites. A certain percentage of clients between the ages of 30-40 are permitted on a site to site basis to receive WISEWOMAN services, but the number of clients must be tracked and monitored to ensure it does not exceed the allowable percentage. Refer to Table 1: HW eligibility at a glance table. Currently, the WISEWOMAN program is offered at a select subset of HW provider sites. CDC allows the WISEWOMAN program to offer a BP+ type visit which is not as extensive a visit as the regular WISEWOMAN visit but meets certain minimum program and CDC criteria for data collection.

The WISEWOMAN Program area is responsible for screening for cardiovascular disease and offering lifestyle interventions; the following are the key program area responsibilities:

• Provide cardiovascular screening for eligible clients

• Provide Initial, Annual, Post Assessment and BP+ screening for clients

• Monitor alert and abnormal screening values

• Provide referrals for diagnostic or other services

• Provide prescriptions for hypertension or other disease medication as appropriate

• Provide healthy behavior and readiness to change assessments

• Provide referrals and linkages to free or low cost community based nutrition, physical activity, pharmacy, and tobacco cessation resources.

• Enroll clients in lifestyle programs and / or health coaching programs following program protocols

• Submit the MDE extracts to CDC twice a year

• Monitor the lost to follow up activity dates and reasons at every stage of the screening

• Capture participation in programs between yearly (11 months or greater) full screenings

• Monitor medical and follow-up referrals and outcomes

• Monitor lost to follow up for LSP and EHC participation

• Conduct post-assessment screenings after client completes LSP/EHC

The WISEWOMAN services are provided to the clients who are participating in HW and who are between the ages of 40-64 years old. As mentioned above, the program allows for a certain percentage of clients to be under the age of 40.The Provider/clinic staff is responsible for recording the client’s demographic information, health history, medication history, insurance status, smoking status, family health history, medication history and status, behavioral risk assessment information, and risk reduction counseling information into the data system designated by the DOH. Some of these data are collected and entered at the HW visit and pre-populate into the WISEWOMAN forms to reduce duplication and potential for data entry errors. There are multiple types of WISEWOMAN screening records: Complete Initial, Complete Annual, Complete Post Assessment records and BP Plus records. There is less data required to be collected on a client in creating a BP Plus record, but a BP+ client may transition into a regular client. In general, clinic staff must collect the measures that are referred to in Appendix J. Appendix M contains the fields, at a minimum, that must be collected for a BP Plus record –other data may be collected and reported but is not required. The provider/ clinic staff is responsible for recording the screening results in to the web based data management system. The referrals for the alert values and abnormal results should also be recorded in the data system. The providers/ clinic staff are responsible for following up with the clients referred for additional medical evaluation. The reasons clients refuse referrals should be recorded in the data system.

At the visit, clients are offered opportunities to participate in Health Coaching (HC) or Lifestyle Programs (LSPs); the availability of which vary by clinic. If the client does not want to participate at the time of the visit, there must be a 30-60 day follow-up call made, which is trackable and able to be queried at any time. The refusal date and reason, at the 30-60 day call must be noted All LSP or HC session contacts are recorded in the system based on type of LSP or HC provided. DOH and local users monitor participation and identify when a client is due for addition LSP or HC sessions according to program protocols. It is important for DOH and local users to monitor and analyze the screening results of client’s pre and post LSP or HC participation. The providers /clinical staff are responsible for submitting the billing information for the services provided to the client periodically to the DOH through the web based data system. The billing system allows for multiple funding types to be utilized based on rules and policies for each service provided.

In preparing to submit the MDE extract to CDC, the DOH users have to perform Program and MDE edit checks. There should be few program or MDE error found in the system at this point. These errors should have be flagged and corrected at the time of data entry prior to permitting the submission of invalid or missing data forms. The web based data system shall perform real time Program and MDE edit checks and create an MDE Extract based on DOH user selected time-frames. The program shall create a complete extract of data for separate data and billing analysis.

In generating the MDE extract, it will be necessary to have the ability to distinguish between a complete record and a BP Plus record based on upcoming CDC or program guidance expected in 2016. These records should be distinguishable in the data extract and the MDE file.

Colorectal Cancer Screening Program:

In June 2009, the Pennsylvania Department of Health was one of 22 states and four tribes selected to receive funding from the Centers for Disease Control and Prevention (CDC) to implement the Colorectal Cancer Control Program (PA CRCCP).

The CRCCP services are provided to both male and female clients who are at average-risk for colorectal cancer, underinsured, uninsured and of age 50 years and older. The targeted population are underserved populations in Philadelphia County who are eligible for colorectal cancer screening services through the PA CRCCP’s provider, the Philadelphia Department of Health (PDOH), a Federally Qualified Health Center Look Alike. The client intake will occur at 7 PDOH sites. The CRCCP provides colorectal screening services to program eligible men and women as recommended by the United States Prevention Services Task Force (USPSTF).

The Colorectal Cancer Screening Program area is responsible for the following services:

• Providing Colorectal screening

• Providing screening through FIT or Colonoscopy

• Performing Biopsy/Polypectomy during colonoscopy

• Monitoring the follow up activity

• Submitting the CCDE extracts to CDC twice a year

• Monitoring the lost to follow up activity

The clients with positive or abnormal screening test results must receive appropriate diagnostic procedures as determined by CDC and CCAC. Clients with positive or abnormal FOBT or FIT must receive a complete colon examination with colonoscopy. The patient navigator is responsible for following up with the patient, and is also responsible for providing patient navigation services to the client. Currently the patient navigator is responsible for capturing the CRC screening results and the billing information in the DOH designated web based data system. All the billing information related to the services provided to the client should be captured in the data system. These services should also include the patient navigation services. For list of patient navigation services, please refer to Appendix M

1 Organizational Profile

|Title |Number of |Division/Bureau|Duties |

| |Positions | | |

|Bureau Director |1 |BHPRR |Oversees the Bureau including the divisions below,|

| | | |along with budgeting duties. |

|Director, Division |1 |HRR |Makes general policy decisions, approves |

| | | |contractual activities. |

| | |CPC | |

|Section Chief |1 |CPC |Acts as liaison to sponsors. Reviews deliverables |

| | | |and provides feedback. Helps resolve issues and |

| | | |policy decisions. Defines project scope, goals, |

| | | |and objectives. Makes high-level strategy, plan, |

| | | |and budget decisions. Resolves risks, issues, and |

| | | |change requests |

| | |HRR |Approves contractual activities |

|Program Manager |1 |CPC |Oversee all activities related to the breast and |

| | | |cervical cancer screening program |

| |1 |CPC |Oversee all activities related to the colorectal |

| | | |screening program |

| |1 |HRR |Acts as liaison to sponsors. Reviews deliverables |

| | | |and provides feedback. Helps resolve issues and |

| | | |policy decisions. Defines project scope, goals, |

| | | |and objectives. Makes high-level strategy, plan, |

| | | |and budget decisions. Resolves risks, issues, and |

| | | |change requests. Responsible for establishing |

| | | |direction and overseeing statewide policy and |

| | | |system change activities for the WISEWOMAN Oversee|

| | | |all activities related to the WISEWOMAN program |

| | | |and manages the program team. Acts as Subject |

| | | |Matter Expert that participates in interviews to |

| | | |document As-is and To-Be business process. |

|Data Manager |1 |CPC |Manages data system, Data validation, Data |

| | | |Submissions to CDC and Acts as Subject Matter |

| | | |Expert that participates in interviews to document|

| | | |As-is and To-Be business process. |

| |1 |CPC |Manages data system, Data validation, Data |

| | | |Submissions to CDC |

| |1 |HRR |Manages data system, Data validation, Data |

| | | |Submissions to CDC |

|Policy, Systems and Environmental |1 |CPC |Responsible for establishing direction and |

|Changes Manager | | |overseeing statewide policy and system change |

| | | |activities for the HW |

| |1 |CPC |Responsible for establishing direction and |

| | | |overseeing statewide policy and system change |

| | | |activities for the CRCCP |

| | | | |

2 High Level ‘As-is’ Process Flow

The business process flow charts below illustrate the business process flow for each of the programs: HW, WISEWOMAN and CRCCP. After each business process flow chart, the program flow it depicts is described in detail. The system shall also provide administrative functions that allow users to be activated and deactivated and given different security roles on an as needed basis.

Currently DOH maintains the HW and WISEWOMAN data in a dynamic web based system, the system stores the following key data:

• Client’s demographic information also including income, insurance, family size, etc.

• Client’s health record. (Both HW and/or WISEWOMAN record)

• Tests and procedures performed

• Medications prescribed

• Types of services provided (LSP’s and EHC’s)

• Follow up schedule

• Provider information

• Types of services provided by a provider site

• Site information

• CPT codes

• Billing Information

The following is the common functionality for both the HW and WISEWOMAN:

The data is extracted from the system with the help of scheduled jobs at least once a month. DOH uses these reports to analyze and validate the data. The main extracts are MDE and PA extracts. The MDE extract is verified by the DOH users and is later submitted to the CDC in the months of April and October. The PA extracts are verified for data accuracy and are used to generate statistical reports based on customer needs. If there is any data discrepancy, the corresponding client’s record is corrected as needed. Records of the clients who received federal funding, either partially or completely, for the services provided by the HW and WISEWOMAN are included in the MDE extract.

Note: Currently all records whose funding source is unknown are also included in the MDE extracts.

Currently DOH maintains the CRCCP data in a dynamic web based system, and the system stores the following key data:

• Client’s demographic information

• Client’s health record

• Tests and procedures performed

• Types of services provided

• Patient navigation services

• Follow up schedule

• Provider information

• Types of services provided by a provider site

• Site information

• CPT codes

• Billing Information

The CCDE extract is verified by the DOH users and is later submitted to the CDC in the months of March and September.

Healthy Woman As-is Business Process Flow

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***Mammogram

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HW is offered to eligible clients at HW designated provider sites. If the provider site is also a designated provider site for WISEWOMAN, the client will be referred to WISEWOMAN if eligible. If the client is interested in the program, the Enrollment and Consent forms along with the HIPPA form are given to the client; the client is enrolled into the HW program. The Provider collects the client’s demographic information, breast cancer history, and cervical cancer history. Client’s breast and cervical cancer history are evaluated, based on the evaluation either or both of the clinical breast exam or the pelvic exam will be performed. Before performing the exam client will be educated on breast and cervical cancer and the exams will be performed only if the client is interested. If client declines the services, the client’s decline reason will be marked in the system and the case is closed.

Note: Provider may enter the data in to the system every time a new intake form is received, but a provider may also wish to data enter at any point in the process flow.

Based on the clinical breast exam results, a screening mammogram or a diagnostic mammogram is performed. Potential future option for 3-D mammogram to be utilized based upcoming protocol to be released in 2016. The mammogram is scheduled and the provider reaches the client for the follow up over the phone, or by mail or email. The mammogram is performed on the scheduled date at the scheduled site. If the client’s clinical breast exam results are abnormal, the provider orders or performs a diagnostic mammogram and if the client’s clinical breast exam results are normal a screening mammogram is ordered or performed at the provider location.

A PAP test is performed based on the pelvic exam results and the client’s PAP and HPV test history. If the client is required to undergo a PAP test, the client is scheduled for the test and the provider reaches the client for the follow up over the phone, or by mail or email. The Pap test is performed on the scheduled date at the scheduled site.

Based on the outcome of the mammogram and PAP test results, one or more of the following services are provided to the client and subject to change based on CDC or DOH requirements:

• Follow-up diagnostic mammogram

• One or more of the procedures mentioned in the note below is performed

• Client is marked for the annual screening

• If cancer is diagnosed, the Client is referred to BCCPT Program for the Treatment

• Follow-up PAP test

Note: The following are the list of current procedures (subject to change based on CDC or DOH requirements) that are performed.

Breast Cancer procedures

• 1. Addl Mamm

• 2. Aspiration

• 3. Aspiration Pathology/Cytology

• 4. Breast Biopsy

• 5. Biop Stereo Guidance -01

• 6. Biop Ultra Guidance – 02

• 7. Biop Surg Incision (MG) -03

• 8. Biop Surg Incision (UG) – 04

• 9. Biop Surg Inc No Image -05

• 10. Biop Surg Exc by Radio – 06

• 11. Biop Surg Exc by Ultra 07

• 12. Biop Surg Exc No Image – 08

• 13. Other Metastatic Workshop

• 14. Other MRI

• 15. Repeat CBE

• 16. Repeat CBE

• 17. Anesthesia

Cervical Cancer Procedures

• Biopsy of Vagina or Vulva

• Cervical Biopsy

• Colposcopy W Biopsy

• Colposcopy With Biopsy and ECC

• Colposcopy With ECC

• Colposcopy Without Biopsy

• Cone Biopsy

• Consultation

• Endocervical Currettage

• Endometrial Biopsy

• Excision of Endeometrial polyp

• Loop Electrode Excision

• Surgical Pathology

• Anesthesia

Note: The list of procedures that are funded by the HW program may change at any point in time.

The follow up process depends on the breast and cervical cancer screening results.

If the results are normal, the provider reaches the client via phone or letter within 30 days of the test. The mode of contact is entered in to the system. The client remains in the system and will be marked for the annual screening. The annual screening process is communicated to the client.

If the results are abnormal, the client is scheduled for the follow up and the client is reached via phone or in-person. After two attempts, if the client is not reached, the provider sends the notification to the client by postal mail. If the client does not respond to the mail notification, a registered letter with a return receipt is sent to the client. If the provider then doesn’t hear back from the client, the client is marked as lost to follow up in the system.

If the client is reached, the provider informs about the follow up services necessary and offers to schedule services. The provider obtains permission from the client to share the abnormal result with the provider who will conduct the follow-up services. If the client refuses follow up services; client’s refusal for further diagnostic services is marked in the system. If the client agrees to follow up; the appointment for the additional diagnostic testing is scheduled. Client receives additional diagnostic testing as required and results are entered into the system.

diagnostic form is created based on abnormal mammogram or PAP test results. If an initial screening or diagnostic mammogram (conventional, digital or 3-D,) is conducted at the intake visit, the results are entered in to the IVSF form; if additional mammograms are conducted, the results are entered in the Breast Diagnostic form. Additional cervical related diagnostic procedures ordered by the provider should be entered on the Cervical Diagnostic Form.

If cancer is not diagnosed, the client is noted in the system for the annual visit. If cancer is diagnosed, the client is referred to the BCCPT program for the treatment and the same is recorded in the system.

During the follow up process, if the provider could not reach the client; the client is marked as lost to follow up in the system. DOH keeps track of all the clients who are marked as lost to follow up. DOH users generate the on demand queries to get the demographic information of all the records that are marked as lost to follow up. Currently system does not send any automated notification or alerts. Provider has to manually mark the clients who need follow up.

From the time of enrollment to the time the final diagnostic/procedures are performed, is considered as one complete cycle. When a client walks in for the annual visit, short term visit, or return/other visit, a new intake form is created and a new cycle begins. A client can have multiple cycles.

As part of entering the initial intake form and screening form, the provider also enters the billing information in the system. For all the services provided to the client; the billing information for each of the services is entered in to the system.

The billing information consists of the following key details:

• CPT code of the services/procedures

• Site code

• Day the services/procedures were provided

• Is billable

• Program funding source

• Amount

Currently DOH users have the ability to enter and edit the CPT codes. The CPT codes potentially may change every year as per the CDC standards. Some of these CPT codes may be combined to create a new CPT code which is assigned for multiple services. These changes are updated in the system periodically and applied throughout the system.

The funds for the HW program are released to the Alliance or Contractor yearly. The Contractor or Alliance will in turn release the funds to its contractors or sub-contractors quarterly. All services billed are to be appropriate to eligibility and need based on established guidelines and protocols. Women screened through the HW program receive all screening and diagnostic services covered through the HW program free of charge.

Cancer Registry Process:

The DOH users have to link the records of the client’s that are diagnosed with cancer to the cancer registry data. Currently, DOH users manually run a query to get the list of clients that are diagnosed with cancer and have not been linked with the cancer registry previously. This list is sent to the cancer registry; cancer registry users will map the DOH list with the registry list and send the list back to DOH with additional MDE required fields. A DOH user validates the list and makes necessary edits if required and saves the additional data. These additional fields are included in the MDE extract.

Note: The same process is followed for CRCCP.

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WISE Woman As-is Business Process Flow

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The WISEWOMAN program is offered to eligible clients at WISEWOMAN designated provider sites. An eligible client walks in at the WISEWOMAN/HW provider site. The client is educated about the WISEWOMAN program. If the client is interested in the program, the enrollment and consent forms along with the HIPPA form are given; the client enrolls in to the WISEWOMAN program. If the client is not interested, the case is closed.

If the client agrees to enroll in to the WISEWOMAN Program, additional data is collected. Some data, such as demographic information, that was collected and entered at the HW visit, pre-populates into the WISEWOMAN forms. This reduces duplication of effort and the potential for data entry errors. The additional data collected for a complete WISEWOMAN screening record is as follows:

• Client’s health history, family’s health history, behavioral risk information and client’s medication status is recorded.

• Client’s height and weight are recorded and based on the values the BMI is calculated.

• Client’s Waist and Hip values are recorded and the WHR is calculated.

• Client’s BP is obtained and is recorded twice; the average of the BP is calculated.

• Client’s blood work results are obtained at the visit or prior to the visit (The blood work results include the Lipid and Hemoglobin A1C values)

The following process is followed to obtain the blood work results:

The blood samples are drawn from the client; before drawing the blood, it is logged whether the client has fasted for at least 9 hours. The fasted lab work is performed and the Lipid panel and Hemoglobin A1C values are obtained. If the client did not fast, the non-fasted lab work is performed and the Cholesterol/HDL and Hemoglobin A1C values are obtained. If the cholesterol is abnormal, the client is asked to repeat the test and fast at least 9 hours and the fasted blood work is performed and the Lipid panel values are obtained.

The client’s health history, family’s health history, behavioral risk information and client’s medication status are taken into the consideration at the time the counselling services are provided to the client.

Based on the client’s Health History, BMI, WHR and the blood work values, the results are evaluated. If the results are all normal the client is provided with the Risk Reduction/Healthy Behavior Support Counselling and the case is closed. At this point the client remains in the system and will be scheduled for the annual visit.

If the results are abnormal, based on the abnormality the client is referred based on the clinical protocol. The following clinical protocols are followed based on the identified abnormalities.

• If the Blood Pressure is abnormal, to include disease level but not alert, the status, follow-up date, treatment provider and type of treatment is recorded in the system.

o Current Medication

o Prescribed Medication

o Medication adjusted

o Referred to alternate provider

o Refused medication

If the Blood Pressure is Disease Level and/or is Uncontrolled HBP, the client is provided with the additional HBP risk reduction counseling. A 2-4 week follow-up visit (call) is made for clients with abnormal blood pressure medication evaluation and is followed by multiple visits for blood pressure medication adjustments.

• If the client is a smoker then cessation referral is recommended and date of referral, type of cessation activity, and completion status are recorded in the system:

o Refer to Quit Line

o Refer to Fax to Quit

o Refer to Community Based Tobacco Program

o Refer to other Tobacco Cessation Resources

• If the Cholesterol and/or A1C/Glucose is abnormal, to include disease level but not alert, the status, follow-up date, treatment provider and type of treatment is recorded in the system.

• then one of the following is recommended and is recorded in the system:

o New/Adjusted medication at Clinic

o Referred to alternate Provider

o Treated by Alternate Provider

o Under the care of Alternate Provider

o Refused Referral -Clinic

o Refused referral -Health Coach

• If the WHR/Waist/BMI is abnormal the client is referred based on the clinical protocol.

After the clinical protocols are followed, the client must be medically cleared for participation in an LSP or Health Coaching. If protocols including referrals and case management result in the client not being medically cleared to participate in an LSP or Health Coaching, the case is closed; at this point client would be eligible for rescreening at their annual screening 11 months from the screening visit.

If the client is medically cleared at the visit, additional risk reduction counselling is provided to the client and the client stage of change is noted. If the client is not ready, the client is marked for a 30-60 day follow up call unless the client refuses. If the client refuses additional services, they are coded as lost to follow up and the case is closed and lost to follow up information is documented.

If the results are alert values, the diagnostic and the case management services are explained to the client. Either additional tests are performed or referrals are made as needed. The status of the workup, workup date, and treatment prescribed are documented in the system.

If the client is medically cleared, risk reduction counselling is provided to the client and the client stage of change is noted. If the client is not ready, the client is marked for a 30-60 day follow up call unless the client refuses. If the client refuses additional services, they are coded as lost to follow up and the case is closed and the lost to follow up information is documented.

If the client is medically cleared and if the client is ready, the goal setting counselling is provided. At this point, the client is directly enrolled in to a Life Style Program or Health Coaching or the client is followed-up after two weeks to enroll in to the program(s).

If the client is unsure about participating in HC or an LSP, a follow-up call is made after 30-60 days, and if the client is ready, the goal setting counselling is provided. At this point, the client is enrolled in the Life Style Program or Health Coaching directly or the client is followed-up after two weeks to enroll in to the program(s). If the client is not ready, the client is marked as lost to follow up and the case is closed and the reason for the lost to follow up is documented. A client can come back and accept the services in which instance the case is re-opened.

• The client is followed up after she is enrolled in to the LSP or HC. This process may involve multiple follow up phone calls. The data for each LSP/HC session and for each follow-up call is documented/ logged in to the system. After the program completion (within 6 weeks post completion of the LSP/HC) the client is required to re-visit. Clients who smoke are referred to cessation programs at sessions, and referrals are documented in the system. The client visits (or calls) the provider site, post assessment data is collected and documented following the same protocols as the screening visit.

If all the results are normal, the client is provided with healthy behavior support counseling and the case is closed and the client remains in the system and will be scheduled for the annual visit.

If results are abnormal, the counselling is provided to the client or referrals are made and the case is closed. The client remains in the system and will be scheduled for the annual visit.

If the results are all alert, the diagnostic and case management services are provided to the client.. Either additional tests are performed or referrals are made as needed. The status of the workup, workup date, and treatment prescribed are documented in the system.

The case is closed and the client remains in the system and will be scheduled for the annual visit.

Note: It is to be noted that the provider can enter the data in to the system at any point in the process, and the process followed for each client may not be the same. The above outlined process is a baseline process and should not be considered as fixed.

As part of the data entry on the screening and assessment form, the provider also enters the billing information into the system. The billing information for each service provided to the client is entered into the system.

The billing information consists of the following key details:

• CPT codes of the services/procedures

• Site code

• Date the services/procedures were provided

• Is billable Program funding

• Amount

• Auth Code

CRCCP As-is Business Process Flow

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CRCCP provides colorectal screening services to eligible men and women. CRCCP is offered to in-reach eligible clients at Philadelphia department of health location.

The client is educated about the CRCCP program. If the client is interested, Patient navigation services are explained to the client. Please refer to Appendix C for a list of patient navigation services. The client is enrolled in to the CRCCP program. If the client is not interested, the case is closed.

As part of the navigation services, the client is educated about the FIT and Colonoscopy procedures. The client can opt for FIT or the colonoscopy.

If the client accepts the FIT test, the instructions on stool testing collection are given, and the client is either provided with the FIT kit or the FIT kit is prescribed. The instructions on returning the FIT kit are given to the client. If the FIT kit is not returned, a follow-up with the client is made via call/ mail. The attempt to reach the client is made three times, if the client is not reached within three attempts; the client is marked as lost to follow up.

If the client is reached and if the FIT kit is returned, the results are explained to the client. If the results are negative, the client is scheduled for the rescreening after a year. If the results are positive a diagnostic follow up is made and the client is referred for colonoscopy.

If the client opts for colonoscopy, the patient navigator verbally explains the colonoscopy procedure; this includes causes of positive results, risks of colonoscopy, bowel prep, use of conscious sedation, and the need for a driver on the day of the procedure. If necessary, a pre-assessment is done. This includes medical clearance, lab testing, electrocardiogram and other studies. Date and time for the procedure is scheduled.

A reminder call is made 24-48 hours prior to the procedure date. In this call, the patient navigator reviews the bowel prep instructions, responds to the client’s questions, informs as to the time of the procedure, and explains the need for a driver due to sedation on the procedure date.

The client arrives at the procedure location after the bowel/ colon prep. If the colon prep results are inadequate, the client is rescheduled for the colon prep and colonoscopy. If the colon prep results are adequate and the colonoscopy is performed, but, no biopsy is necessary, the client is marked as re-screen after 3-10 years and the client remains in the system. If the colonoscopy is performed and biopsy is necessary, but, no cancer diagnosis is made, the client is marked as re-screen after 1-5 years and remains in the system. If cancer is diagnosed, the client is referred for treatment and the case is closed.

Note: It is to be noted that the provider can enter the data in to the data system at any point in the process.

3 High Level ‘To-Be’ Process Flow

There are no potential changes to the actual business process flow of each individual process; the actual business process flow remains As-is. The new web-based application will be an integrated system that can be used by HW, WISEWOMAN and CRCCP users. The web based data system will be automatically updated by the contactor to align and maintain compatibility with updated CDC protocols for the programs when released. The web based data system will uphold the data of HW, WISEWOMAN and CRCCP program areas. The significant changes will impact both internal users and external users. DOH users and external users will rely on the dynamic reporting capabilities of the new system. The HW, WISEWOMAN and CRCCP program will need the capability of generating multiple reports for decision making, statistics, state and CDC reporting, and quality assurance of the services provided at the provider sites.

The web based data system shall perform the real time MDE/CCDE checks; which will minimalize the time of MDE/CCDE data validations. This will allow the DOH users to focus on analyzing the data extracts rather than verifying the data extracts. The new data system shall have ability to set alerts for the user defined activities like appropriate follow-up actions, submitting the billings etc. The providers/ clinical staff shall have ability to run reliable user defined or system defined reports. The web based data system shall provide the capability of associating client record to different applicable programs; this functionality will reduce the data redundancy.

The DOH admin users shall have privileges to assign user roles with defined accessibility to the system. DOH users shall have ability to retrieve on demand reports for the CPPI reports and program performance statistic reports. The new system shall allow the DOH user to add, modify or delete various validations. Having the flexibility, the system shall allow the DOH user to define rules for each individual program. It shall maintain the client history and shall have ability to retrieve and export the historical data.

The robustness of the new system shall simplify the association between the HW and CRCCP client records with the cancer registry records. This functionality will considerably reduce DOH user’s effort. See streamlined Registry flow below.

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4 Process Mapping

The key objective of the new web based data system is to provide a shared platform for HW, WISEWOMAN and CRCC program users and to maintain client data and their subsequent service details in a structured manner. It will allow providers\ clinical staff to enter, store and view the client’s information. It will provide role based access to a number of internal and external users (see Figure 1), allowing each user group to enter and view their information in the system. As the system contains HIPPA protected data, it will be critical that adequate security checks be in place to ensure only authorized access to confidential data.

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Figure 1: HW, WISEWOMAN and CRCC Data System End Users

The systematic layout of the data entry forms in the system shall ease the navigation within the data system. Considering the fact that any eligible individual client can enroll into more than one program, the new system shall have capability of linking the client to multiple programs; this ability will reduce the redundant data entry. The real time data validations and MDE checks by the system will eliminate the data inconsistency and reduce the time spent on manual validation. To maintain the data accuracy and data integrity, the system shall be capable of verifying the data at the time of input, and shall not allow the data entry unless and until the data is corrected or the validations are suspended by the DOH users.

The canned and ad-hoc reports will be available for various purposes and for various levels of users to assist them in decision making, program improvement and in monitoring the provider and site activities. The system will generate notification reports, alerts and reminders to keep track of the clients’ follow-up and scheduling activities. The new web based system shall provide the ability to generate user defined reports; allowing the user to get statistical data for the defined values.

The system will generate automated and on-demand data extracts through a secure FTP site which must allow selected users to download files, upload files for the contractor, create directories, and delete files. Since the new data system shall be accessible by the multiple user groups, the system shall provide restricted data access based on the user roles and predefined system rules.

The data system shall have the ability to export reports to a readable format. Since exporting a large amount of data may impact the system performance, the export functionality will be available only for limited amounts of data. The system shall provide the ability to export large amounts of data through nightly jobs.

The data system shall have the ability to import, save and link the cancer registry data to the existing clients in the system. The system shall also provide the ability to extract the cancer registry data from the system. This functionality shall be applicable for both HW and CRCC programs.

The system shall provide the ability to generate labels, emails and letters for the user defined list of clients. The system shall provide billing reports; these billing reports shall be user defined and system defined reports. The data system shall alert the providers to submit the billings as per the defined submission rules. This ability will eliminate late and missing bills. The system shall maintain the client’s historical data and shall allow the users to retrieve historical data as needed.

The following figure (Figure 2) illustrates some of the key inputs and outputs of the integrated web based data system.

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Figure 2: HW, WISEWOMAN and CRCC Data System Inputs and Outputs

Requirements Definition

1 Overview

This section outlines the approach used to define the high level business requirements and system requirements. It includes the tools used for requirements gathering, HLBRD and detailed system requirements document.

1 Approach

The method below details the approach that was used to gather and document the system requirements:

• Analyze and understand the existing systems

• Comprehend the existing business related documents

• Conduct interviews with HW, WISEWOMAN, CRCC individual program team members

• Identify gaps in the existing system based on user needs

Once the current business process and the data requirements were better understood, multiple JAD sessions were conducted to define detailed system requirements. DOH Project Management Office (PMO) Requirements Tool template was used to document the business requirements, system requirements, and traceability.

2 Detailed Requirements

The detailed requirements are documented in the Requirements Tool. Please find the attached worksheet which includes HLBR, Detailed System Requirements and traceability. For each system requirement; the category, sub-category, ID, priority, and source is specified in the worksheet.

1 High Level Business and System Requirements

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Addendum

Appendix A

• Height and Weight

• Body mass index (BMI)

• Waist measurement

• Hip measurement

• Waist-to-hip ratio (WHR)

• Blood Pressure (must record two systolic and two diastolic measurements taken at least 5 minutes apart.) The average blood pressure is used to determine the normal, abnormal, or alert status for WISEWOMAN)

• A1C (Fasting Blood Glucose if an A1C is unavailable. Non‐fasting glucose testing is not an allowable service)

• Blood cholesterol - Fasting or non-fasting total and HDL cholesterol, at minimum (If clients are fasting, a lipoprotein panel should be used, (includes LDL cholesterol and triglycerides). If client has a non-fasting abnormal blood cholesterol, she should be referred for a fasting test.

• Smoking behavior

• Personal history of high cholesterol, high blood pressure, diabetes, and medications for these conditions

• Personal history of coronary heart disease/chest pain, heart attack, heart failure,

• stroke, transient ischemic attack (TIA), vascular disease, or congenital heart defects

• Personal and family history of heart attack, stroke, or diabetes

• Healthy Behavior Assessment regarding medication adherence, self‐monitoring of blood pressure, consumption of fruit, vegetables, fish, whole grains, sugary drinks, sodium, amount/intensity of physical activity, and quality of life (physical, mental) and its impact on usual activities

• A1C (preferred) or Fasting Blood Glucose

• Blood cholesterol - Fasting or non-fasting total and HDL cholesterol, at minimum

• (If clients are fasting, a lipoprotein panel should be used, (includes LDL cholesterol and triglycerides). If the client has abnormal non-fasting blood cholesterol, a fasting test must be done to qualify for reimbursement.

Appendix B

A BP Plus WISEWOMAN screening record must contain at least the following information:

• Date of Birth

• History of high cholesterol, HBP, or diabetes

• Medication status: high cholesterol, HBP, or diabetes

• Smoking status

• Height and weight

• Blood Pressure date – first systolic and first diastolic bp measurements

Appendix C

• Patient Navigation services include: phone calls, face-to-face contact, letters, and providing educational materials. During the initial contact the Patient Navigator provides core services:

• Confirms patient eligibility (age appropriate, uninsured, average risk screening criteria)

• Provides education on the CRC program and assistance that is offered

• Provides patient education (screening options such as colonoscopy or FIT)

• Addresses patient concerns (unpleasantness, convenience, cost etc.).

• Schedules appointments

• Discusses colonoscopy

▪ Colonoscopy procedure (sedation, digital rectal exam, colonoscopy)

▪ Different types of polyps

▪ Colon cancer symptoms

▪ Screening and screening guidelines

▪ Gastrointestinal practice to use and the hospital location

▪ Free bowel preparation and explanation of procedure

▪ Preparation and expectations the day before the colonoscopy

▪ Possible side effects/risks involved with the procedure

▪ Recovery after the colonoscopy

• Fecal Immunochemical Test

▪ Description of the FIT

▪ How to complete FIT testing at home

▪ Importance of returning the test to the health center

▪ Procedure following a positive or negative test result

Glossary of Terms

Table: Glossary of Terms used in This Document

|Term |Definition |

|A1C |Hemoglobin A1c test ‐ also called HbA1c, glycated hemoglobin test, or glycohemoglobin |

| |Hemoglobin A1c ‐provides an average of blood sugar control over a six to 12 week period. |

|CBE |Clinical Breast Exam; external exam of breast and surrounding tissue (supraclavicular and |

| |axillary node regions) by medical professional |

|Clinical Staff |Clinical staff that potentially enters the data in to the web based data management system. |

|Colonoscopy |Colonoscopy is the endoscopic examination of the large bowel and the distal part of the |

| |small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the |

| |anus. It can provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity|

| |for biopsy or removal of suspected colorectal cancer lesions. |

|CPPI |Core Program Performance Indicators established for the National Breast and Cervical Early |

| |Detection Program (NBCCEDP) by the CDC; list of HW priority performance indicators (i.e., |

| |timeliness and adequacy of follow-up) |

|CPT |Current Procedural Terminology; descriptive terms and identifying codes for reporting |

| |medical services and procedures performed by physicians according to ICD-9 manuals and |

| |program requirements. |

|Data System / Web Based Management |New integrated data system that will be in place for online data management of HW, WISEWOMAN|

|Data System |and CRCCP programs data. |

|HC |Health Coaching is a series of program options where woman receive health coaching in |

| |conjunction with an established focus (multiple health coaching programs are available |

| |dependent upon the site and are recorded in the system based on DOH requirements). |

|FIT |The fecal immunochemical test (FIT), also called an immunochemical fecal occult blood test |

| |(iFOBT), is a newer kind of stool test that also detects occult (hidden) blood in the stool.|

|HPV |Human Papillomavirus; a group of more than 100 types of viruses some of which can cause |

| |warts (papilloma). Some HPVs are sexually transmitted and also cause cervical cancer |

|LEEP |Loop Electrosurgical Excision Procedure; medical procedure to remove abnormal tissue from |

| |the cervix for further analysis or treatment; procedure is only covered as a diagnostic test|

|LSIL |Low Grade Squamous Intraepithelial Lesion; cytology result of a HW Pap test or cervical |

| |biopsy requiring additional follow-up in 6 months |

|LSP |Life style programs are one of the WISEWOMAN healthy behavior support options to which |

| |programs can refer women. Through participation in an LSP, women learn about healthy |

| |behaviors and receive support on how to integrate these behaviors in to their daily life. |

|NBCCEDP |National Breast and Cervical Cancer Early Detection Program; administered by the CDC in 50 |

| |states and territories. In Pennsylvania, the program is known as the HealthyWoman Program |

| |(HW) |

|PAP |The Papanicolaou test (abbreviated as Pap test, known earlier as Pap smear, cervical smear, |

| |or smear test) is a method of cervical screening used to detect potentially pre-cancerous |

| |and cancerous processes in the endocervical canal (transformation zone) of the female |

| |reproductive system. |

|PROVIDER SITE |An individual or entity is a subgrantee with a signed contract to provide services to women |

| |enrolled in the HW/ WISEWOMAN/ CRCCP ; the location where women enroll in the program(s) and|

| |receive screening services, case management, referrals, tracking, and follow-up |

|RPM |Regional Program Manager; primary contact for specific service provider sites on |

| |HW/WISEWOMAN issues. Currently four regional program managers are responsible for the |

| |HW/WISEWOMAN programs oversight at each site. Potential capacity to add new RPM and identify|

| |the specific sites under each RPM is needed. |

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