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The Primary Care Information Project How Can Government Get Value From HIT?

The Primary Care Information Project How Can Government Get Value From HIT?. New York City Department of Health and Mental Hygiene. www.nyc.gov/pcip. Presentation developed by Farzad Mostashari, MD MSc. On ABCS of prevention, USA Gets an “F”.

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The Primary Care Information Project How Can Government Get Value From HIT?

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  1. The Primary Care Information ProjectHow Can Government Get Value From HIT? New York City Department of Health and Mental Hygiene www.nyc.gov/pcip Presentation developed by Farzad Mostashari, MD MSc

  2. On ABCS of prevention, USA Gets an “F” • People at increased risk of CVD who are taking Aspirin. • – 33% • People with hypertension who have adequately controlled Blood pressure • – 44% • People with high Cholesterol who have adequately controlled hyperlipidemia • – 29% • Smokers who try to quit get help • – 20% Despite spending nearly 1 out of every 6 dollars on health care

  3. Most Room For Improvement Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of Preventive Services to Older Adults by Primary Care Physicians. JAMA. 2005; 294:473-481.

  4. Few Quality Improvement Tools * Model controls for practice size, years in practice, hours a week in direct patient care, salary status, physician type (primary care vs. specialist), certification status in specialty, and use of EMR. Audet AMJ, Doty MM, Shamasdin J, Schoenbaum SC. Measure, Learn, And Improve: Physicians’ Involvement In Quality Improvement. Health Affairs. 2005; 24: 843-853.

  5. Health IT has the potential to improve the quality of care we deliver…

  6. State of Health IT on the Ground • Most ambulatory care in the US is provided in small office settings (1-5 providers) but only 11-15% of these offices have a health IT system. Adoption of HIT in Physician Practices, by size2 Delivery of ambulatory care in the US1 > 11 physicians 1-2 physicians 6-10 physicians Percentage 3-5 physicians 1 2-5 6-15 16-30 > 30 Number of physicians in a practice DesRoches CM, Campbell EG, Rao SR, Donelan K, Ferris TG, Jha A, Kaushal R, Levy DE, Rosenbaum S, Shields AE, Blumenthal D. Electronic health records in ambulatory care--a national survey of physicians. N Engl J Med. 2008 Jul 3;359(1):50-60. Epub 2008 Jun 18.

  7. Health Care Reform and Health Information Technology • Health IT is endorsed as an essential element of health care reform, and we are investing heavily in its success • Various expectations • Will reduce costs dramatically1,2, 3 • Will improve quality and safety of care4 • Will enable cost-effectiveness analyses5 • But it is equally possible that we will spend billions of dollars without public benefit 1. 30 Minute Program: American Stories, American Solutions. Christopher Hass. 2008 2. Center for Information Technology Leadership. The Value of Healthcare Information Exchange and Interoperability. 2004 3. Girosi F. Meili R. Scoville R. Extrapolating Evidence of Health Information Technology Savings and Costs. RAND. 2005 4. Center for American Progress. The Healthcare Delivery System: A Blueprint for Reform. Chapter 1. 2008 Congressional Budget Office. Evidence on the Costs and Benefits of Health Information Technology. 2008

  8. Challenges to Health Reform through HIT Providers have competing practice priorities and limited resources Financial burden of adoption on provider, benefits accrue to insurance Reimbursement is claims-driven Additional quality of care delivered with the EHR (smoking counseling, email messages, panel management) may hurt the practice financially. Existing Pay-for-Performance programs too disperse to achieve results Data required for quality measures reporting not uniformly recorded Standards for safe, interoperable data transmission not yet established 8

  9. What Is the Role of Government? • Ensure HIT addresses priority public health issues • Prevention • Quality of care • Coordination of care • Reimbursement reform • Disparities in health outcomes

  10. HEALTH INFORMATION SYSTEMS oriented toward prevention CARE MANAGEMENT so practice workflows support preventionand PAYMENT that rewards diseaseprevention and effective chronic disease management PATIENT EMPOWERMENT to prevent disease and disability Health Care that Maximizes Health

  11. Mission Increase the quality of care in medically underserved areas through health information technology (HIT) Goals Extend EHRs that support prevention to 2,500 Medicaid PCPs,over 1.5 million patients Provide practices with clinical quality scorecards and practice redesign technical assistance Design and implement pay-for-performance incentive program that supports and recognizes preventive measures NYC Primary Care Information Project

  12. Resources NY City: $30 million and 60 staff Practice contributions: >$15 million NY State: $11 million Federal: $5 million (AHRQ, CDC) Private: Robin Hood Fund $4-6 million, Wellpoint Foundation $500,000, HIP/GHI $150,000 NYC Primary Care Information Project

  13. PCIP Progress (March ‘09) • Signed Agreements • 4 Hospitals – 741 providers • 30 CHCs – 627 providers • 366 small practices- 812 providers • 2180 providers total • Live on EHR • 273 practices • 381 sites • 1531 providers

  14. Eligibility/ Commitment Primary Care Underserved populations (10% Medicaid, uninsured) Quality Measure Reporting (summarized, confidential) Financial Commitment Hardware and Internet $4k per provider QI fund PCIP Package Licenses to eClinicalWorks “TCNY” integrated EHR On-site training, interfaces 2 years software maintenance and support ($1500/yr) PCIP EHR Extension Approach

  15. Key Features of the TCNY Build AUTOMATIC VISUAL ALERTS Highlights abnormal vitals COMPREHENSIVE ORDER SETS Displays best practice recommendations (meds, referrals, procedures, labs, patient ed) 1 4 CDSS Automatically displays TCNY measure alerts for comprehensive preventive care MEASURE REPORTS Summary of provider performance on quality measures 5 2 QUICK ORDERS One-click ordering of recommended preventive services ENHANCED REGISTRY Identifies patient panels by diagnoses, drugs, labs, demographics and structured data 6 3

  16. The following storyline illustrates the TCNY Clinical Decision Support System in action Jane Doe, a 48 year-old woman has come to her family practitioner, Dr. James Bear, for an annual exam.

  17. Jane Doe has come for her annual exam • During the visit, Dr. Bear’s assistant takes her history and vitals • Jane mentions that she has had a few weeks of excessive thirst and fatigue Jane’s blood pressure is elevated (150/90) and highlighted in red by the AUTOMATIC VISUAL ALERT FUNCTION. Dr. Bear can trend her BP over time.

  18. Based on Jane’s complaint of excessive thirst, Dr. Bear performs a glucose fasting test and confirms his suspicion that Jane has diabetes • Dr. Bear enters a diagnosis of diabetes into the EHR Based on Jane’s new diagnosis of diabetes, the CLINICAL DECISION SUPPORT FUNCTION identifies four preventive care services that should be performed. This list of services is automatically populated in the CDSS panel.

  19. Dr. Bear agrees that these tests are appropriate and should be performed The QUICK ORDER FUNCTION allows Dr. Bear to order an HbA1C test for Jane, as well as a flu vaccine; the alerts disappear from the panel once they are ordered. Dr. Bear may also choose to suppress alerts, if he deems them unnecessary.

  20. Dr. Bear also selects the “LDL control (high risk)” alert, which displays the order set for high LDL levels The 1st part of the COMPREHENSIVE ORDER SET displays a selected list of recommended medications (brand & generic) for lipid control.

  21. Dr. Bear views other options for high LDL levels to provide comprehensive care The 2nd part of the COMPREHENSIVE ORDER SETdisplays a selection of recommended labs, immunizations, follow-up appointments, referrals as well as printable physician and patient education materials.

  22. Dr. Bear wants to find out how he is performing in controlling high blood pressure for his other diabetic patients. Using the QUALITY MEASURE REPORTS FUNCTION, Dr. Bear sees that one-third of his diabetic patients have achieved good BP control.

  23. Dr. Bear wants to improve his score on BP control and queries the EHR to identify patients with poorly controlled hypertension Using the ENHANCED REGISTRY FUNCTION, Dr. Bear identifies five patients with high blood pressure who do not have scheduled appointments and reaches out to each by generating follow-up visit letters. When these patients come in, they will receive BP control therapy and a full range of preventive services suggested by their CDSS alerts.

  24. Alerts • 34 prevention-focused quality measures • USPSTF • NCQA • NQF • TCNY

  25. Quality Reporting Draft Practice Results: ABCS and Comparison to NYC Average B Blood Pressure Control (Overall) A Aspirin S Smoking Cessation C Cholesterol Control (Overall)

  26. Health eHearts A pilot incentive program to reward providers for delivering excellent preventive care for cardiovascular health • Average Provider can earn between $10,000 to $20,000 • Maximum cap for any practice is $100,000

  27. What Does the Future Hold? Expanding health information exchange Panel Management Pilot Patient Engagement Public Health Reporting Building a social network Becoming a Regional Extension Center Stimulus $$

  28. Stimulus • Authorizes $19B for health IT • $17B in electronic reimbursement incentives • $2B for standards development and capacity-building • Providers eligible for $40-65k when submit data electronically • Doesn’t solve upfront costs: $24-40k/provider • Potential to aggravate existing disparities • Loophole: State-designated extension centers

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