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Physician Adoption of HIT

Alliance. of Chicago Community Health Services, LLC . Physician Adoption of HIT. Implementation of EHRS as a tool for quality in the Safety Net. Fred D. Rachman, MD AHRQ Annual Conference September 26, 2007. Presentation Overview. Describe our vision for implementation of EHRS

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Physician Adoption of HIT

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  1. Alliance of Chicago Community Health Services, LLC Physician Adoption of HIT Implementation of EHRS as a tool for quality in the Safety Net Fred D. Rachman, MD AHRQ Annual Conference September 26, 2007

  2. Presentation Overview • Describe our vision for implementation of EHRS • Describe our implementation approach and status of use • Share observations

  3. Comparison of Adoption Rates

  4. Alliance Overview • HRSA funded Network of 4 Federally funded Health Centers located on the Near North Side of Chicago • Founded based upon long standing history of collaboration and close relationship among Medical Directors • Health Centers target Latino, African American, Gay and Lesbian, and Immigrant and Homeless populations • Services encompass comprehensive Primary Care, Dental, Mental Health and Social Services, Health Education, and Research

  5. Alliance Purpose • Essentially a joint venture of four independent organizations with the desire and ability to work together on building some common infrastructure to improve service delivery and health status • Dedication to quality • Ability to access higher quality, efficiency and economy of scale • Desire to ultimately share with others

  6. Map of Sites

  7. The Status Quo • Overwhelmed practitioners seeing high volumes of patients with limited support • Lack of coordination/communication between supportive services and medical providers and among settings of care • Limited time for interactions • Difficulty accessing information in timely/organized fashion

  8. Impetus for the project INSERT CARE MODEL

  9. Study in JAMA found that missing information from charts could, 44% of the time, adversely impact patient’s well-being • RAND - patients receive appropriate care 55% of the time • CDC found that elderly patient visits to physicians result in a projected 17.6 million prescription errors yearly

  10. Building Clinical Consensus • EHRS project began as a strategic planning priority for clinical leadership at partner health centers. • Clinical leadership heavily involved in product evaluation and selection. • Monthly meetings, conference calls, site visits and retreats for clinical leadership in the planning phase of implementation.

  11. The Alliance Vision for EHRS • Useful and practical at the point of care • Holistic – promoting multidisciplinary model of care • Integrated with other electronic health data bases to promote efficiency and continuity • Tool for incorporating evidence based recommendations into practice • Capable of providing data and reporting to support the care model

  12. Capabilities of Electronic Record Systems Basic a storage and retrieval system VS Advanced a sophisticated interactive database 6/5/2014

  13. Considerations in implementing higher level functionality Acceptance of common vision of quality Adoption of evidence based standards against which to judge care quality Agreement to conform to standardized ways of recording data Ability to capture and process relevant data Relevant care elements are captured as structured information Implies that “order entry” is computerized Data is “clean” and consistent 6/5/2014

  14. Key decisions • Chronic Care Model to manage disease and populations of patients. • Network wide clinical standards. • Promote use of standardized templates /forms and structured data collection across all health centers. • Utilize national experts and evidence based protocols as basis for standards of care. • Utilize internal/local subject matter experts to review standards and support development of the end user screens.

  15. EQUIP project goals 1. Implement EHRS in a network of Community Health Centers in a manner that ensures consistency and accuracy of health information across all practitioners, sites and populations. 2. Develop a data warehouse that will monitor, aggregate, and provide data to be used for clinical and system quality improvement. 3. Utilize the EHRS/data warehouse to facilitate and encourage the use of evidence-based practice measures at the point of care.

  16. EQUIP project goals 4. Utilize the EHRS/data warehouse to facilitate continuous improvement of health care quality and safety and develop its function as a patient registry. 5. Promote and support the realization of the full potential of EHRS use in ambulatory care settings, particularly among safety net providers, to improve health care quality and safety.

  17. EQUIP Partnership • American Medical Association • Health Information Management Systems Society • GE Healthcare Clinical Data Services • First Consulting Group • Health Research and Education Trust

  18. Key elements of Alliance EHRS Development • Structured data entry • Ease of data entry to encourage providers to capture needed information as part of care delivery • Agreed upon protocols against which to benchmark care • Content to include full spectrum of care (eg, mental health/case management) • Mapping of data elements to care protocols

  19. Key elements of Alliance EHRS development • Reporting algorithms that incorporate appropriate inclusion and exclusion criteria • Export to a data warehouse for more sophisticated data uses • Dedicated resources and an approach to introducing systems changes to produce improvement

  20. Implementation Approach • Clinical Champions • Customized development with user involvement • Extensive training and education • Incorporation of change management • Interfaces with practice management system and laboratory system • Preload of key information as data and electronic import of historic laboratory data • Full functionality of all providers at go live

  21. Key aspects of implementation • Individual site sponsorship • Change management • Training/education • Project management • Workflow redesign • IT infrastructure development

  22. Practice Guideline Structured Data Entry Decision Support Patient Status

  23. Status of System use • Live at main sites of all 4 Health Centers • 125 concurrent users, approximately 225 individual users. • “Big Bang” - All staff, with full functionality of the system • Productivity at pre-implementation levels • Next wave of Alliance sites to go-live beginning in June • Planning implementation at first non- Alliance sites

  24. Current use • System in use across 4 organizations at major sites • 180 concurrent users; more than 350 named users • Dashboards deployed: system use, clinical measures, user satisfaction, patient satisfaction

  25. Utilization • Ongoing support/help desk • Ongoing interface development/management • Continued workflow redesign • Ongoing development of user interface • Report development and utilization • Data management and use • Updates

  26. Future potential • Provider education • Patient access - building toward PHR • Secure messaging to other providers • Telemedicine • Public Health database interfaces • Emergency preparedness • Research infrastructure

  27. Fewer than 10% of physicians are using EHRS with full functionality such as electronic prescribing or computerized order entry. “ How Common Are Electronic Health Records In The United States? A Summary Of The Evidence”, Health Affairs no. 6 (2006): w496-w507, Ashish K. Jha, Timothy G. Ferris, Karen Donelan, Catherine DesRoches, Alexandra Shields, Sara Rosenbaum and David Blumenthal • In the private sector, there are potential revenue gains through EHRS adoption, In community Health Centers, the major driver for EHRS adoption is quality The Value of Electronic Health Records in Community Health Centers: Policy Implications, Robert Miller and Christopher West, Health Affairs 26 no 1, (2007)206-214

  28. Some of the Challenges to EHRS implementation • Complexity and cost • Access to appropriate IT expertise across phases of project (plan, design, build, implement, support) • Crosscutting organizational priorities/challenges in EHRS implementation at Center level • Interfaces • Vendor relationships • Variation and lack of appropriate specificity in national performance measures

  29. Measure Example Diabetes Measurement Set (foot exam) • Measure:Percentage of patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam) Numerator = patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam) Denominator = All patients with diabetes 18-75 years of age

  30. Technical SpecificationsNumerator • Patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam) • Note: All three components must be completed within the reporting period but they do not have to be completed at the same visit.

  31. Technical SpecificationsDenominator • All patients with diabetes 18-75 years of age • Codes to identify patients with diabetes include: • ICD-9-CM Codes: 250, 357.2, 362.0, 366.41, 648.0) (DRGs) 294, 205 • Prescriptions to identify patients with diabetes include: • Insulin prescriptions (drug list is available) and Oral hypoglycemics/ antihyperglycemics prescriptions (drug list is available)

  32. Technical SpecificationsExclusions • Exclude patients with a diagnosis of polycystic ovaries (ICD-9-CM Code 256.4) who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year. • Exclude patients with gestational diabetes (ICD-9-CM Code 648.8) or steroid-induced diabetes (ICD-9-CM Code 962.0, 251.8) during the measurement year • Patients with bilateral foot/leg amputation • ICD-9-CM exclusion codes for 2.9 Foot Exam: 896.2, 896.3, 897.6, 897.7 • Other reason documented by the practitioner for not performing a complete foot exam

  33. Adult Use of diabetes disease management form Use of cardiovascular disease management form Use of HIV disease management form Use of Asthma disease management form Mammogram BIRAD score documented PAP Results documented Colonoscopy Screening documented Adolescents Sexual Activity documented at office visit Violence risk documented at office visit Pediatrics Developmental assessment documented Weigh percentile documented Height percentile documented Head circumference percentile documented OB/GYN Prenatal visit with documented EDC Prenatal visit with FHR documented Prenatal visit with genetic history documented Mental Health Established treatment plan date documented Treatment plan revision date documented Signed metal health assessment documented Substance abuse screening documented System Use Measures

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