Case Overview: New York City Electronic Health Record (EHR) Implementation

1. Case Overview: New York City Electronic Health Record (EHR) Implementation Source: NYC Tourist Laura Pitarys Keio University March 11, 2014

2. Main Points The New York City EHR program’s success: • Targeted approach • Strong government support in implementation and funding • Public Health objectives • Transparency in results • Innovative pilots

3. Agenda • NYC Health Policy Overview • Primary Care Information Project (PCIP) Overview • PCIP Mission and Objectives • Addressing Privacy and Security Issues • PCIP Funding and Financing • Evaluations, Results and Challenges • Looking Forward/Next Steps

4. Hurricane Sandy: October 29, 2012 Source: New York Daily News $50B damage in the US 117 lives lost Sources: CDC and NHC Source: NYC DOHMH

5. New York City Health Policy Environment

6. Health Snapshot Sources: NYC Department of City Planning,, NY Times, United Hospital Fund and NYC DOHMH.

7. Health Snapshot Sources: NYC Department of City Planning,, NY Times, United Hospital Fund and NYC DOHMH.

8. Medically Underserved Areas in NYC Sources: US Dept. of Health and Human Services and New York World

9. NYC Primary Care Information Project Overview

10. Terms

11. Terms

12. Terms, cont.

13. Terms, cont.

14. Background

15. Criteria: The Key to PCIP is Point of Care & Preventive Care Diagnosis Outpatient Inpatient

16. Criteria: Those most in need of medical care

17. Public Policy Objectives • PCIP was intended to help improve preventative care, particularly those at risk for chronic diseases. • Areas of health policy concern in NYC include: obesity, Type II diabetes, cardiovascular health, high blood pressure and smoking cessation.

18. Public Policy Objectives • The PCIP metrics were aligned with the public health Take Care New York (TCNY) core areas (strategic health policy priorities). TCNY PCIP

19. Take Care New York 2012 Priorities

20. EHR Implementation • NYC Dept. of Health (DOHMH) chose one EHR vendor for implementation. • eClinicalworks, the selected vendor, had a successful track record when Massachusetts providers were given an option in the Mass. EHR initiative.

21. EHR Implementation Small Practice EHR Vendors Source: IDC Health IT Strategy 2012

22. Evolution of EHRs

23. NYC PCIP Mission and Objectives

24. PCIP Mission Patient Centered Approach Patients are able to see lab results, prescriptions and make appointments and communicate with doctor online. Clinical Quality Improvement Ability to aggregate data to evaluate the quality of preventive care as well communicable disease outbreaks. Clinical Decision Support System reads patient data and gives providers suggested interactions or potential at-risk for chronic disease.

25. EHR Capabilities Provider PCIP Patient (PHR) Labs Pharmacy

26. EHR Capabilities Primary Provider Hospitals / Specialists PCIP Patient (PHR) Labs Pharmacy

27. EHR Capabilities

28. Patient Centered Approach Patient Centered Approach Patients are able to see lab results, prescriptions and make appointments and communicate with doctor online. • Patients are encouraged to educate themselves about their health and actively manage any conditions. • Email communication with doctors is enabled as are scheduling capabilities and prescription refill requests.

29. Patient Portal

30. Patient Portal Snapshot

31. Patient Portal Snapshot

32. Patient Portal Snapshot

33. Clinical Quality Improvement • Pay-for-performance (P4P) based on effective utilization of the system • Medicine recall alerts: Alerts sent from the Department of Health to providers through EHR system. Clinical Quality Improvement Ability to aggregate data by clinic/hospital to evaluate the quality of preventive care as well communicable disease outbreaks.

34. Clinical Quality Improvement • Comparative dashboard reports available to clinicians by PCIP. • No identifiable patient data is transmitted to the Dept. of Health!

35. Dashboard Source: DOHMH

36. Dashboard Details Source: DOHMH

37. Clinical Decision Support System (CDSS) • Based on clinical and demographic information entered (e.g. patient with chronic disease), the system requires prompts for additional questions/information. • The system stores the answers to prompted questions, lab results, prescription information and vital signs. • Alerts for missing data. Clinical Decision Support System reads patient medical history and data and gives medical providers suggested interactions or potential at-risk for chronic disease.

38. Clinical Decision Support • An example of the parameters for Type II diabetics is: • At least 18 years of age and • Body Mass Index of > 25, > 22 if Asian and • Pre-diabetes diagnosis (i.e., fasting plasma glucose: 100-125 mg/dL, oral glucose tolerance test: 140-199mg/dL, or A1C: 5.7-6.4%) • Source: NYC Department of Health and Mental Hygiene

39. EHR Results & Effectiveness Source: NYC Department of Health and Mental Hygiene

40. EHR Results & Effectiveness Source: NYC Department of Health and Mental Hygiene

41. NYC PCIP: Issues of Privacy and Security

42. Privacy Issues

43. Privacy Issues Breach Notification New York State Public Health Law also has its own provisions on patient privacy. Enforcement

44. Privacy Law Impacts on EHR Examples of EHR privacy/security setting from PCIP. Source: New York City DOHMH.

45. Privacy Law Impacts on EHR, Cont. Examples of EHR privacy/security setting from PCIP. Source: New York City DOHMH.

46. Privacy Enforcement Data breaches of 500+ must be reported to media outlets and affected patients.

47. Electronic Consent Forms In New York, a patient must opt-in and actively consent to care. Practices are able to customize the content of the Practice Consent Form. Source: Housing Works.

48. NYC PCIP: Funding and Financing

49. Subsidies: How much and from whom? The original funding for PCIP was City Tax Levy ($30M).

50. Who pays for what? Patients pay nothing for the system or access to the patient portal Providers pay a $4,000 contribution to offset the costs of implementation and training.