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EHR IMPACT ON QUALITY PROCESS MEASURES AND POPULATION HEALTH IMPROVEMENTS. Kwame A. Kitson, MD VP of Quality Improvement Institute for Family Health 16 East 16 th St New York, NY 10003 kkitson@ institute2000.org 212-633-0815 www. institute2000.org. Cambridge, Massachussetts
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EHR IMPACT ON QUALITY PROCESS MEASURES AND POPULATION HEALTH IMPROVEMENTS Kwame A. Kitson, MD VP of Quality Improvement Institute for Family Health 16 East 16th St New York, NY 10003 kkitson@ institute2000.org 212-633-0815 www. institute2000.org Cambridge, Massachussetts August 20, 2008
IFH AT A GLANCE • Geographic area – Manhattan, Bronx, New Paltz, Kingston, Ellenville, Hyde Park, Port Ewen. • 15 Community Health Centers • 8 Care for The Homeless Primary Care Sites • One School Based Health Center • Two FP Residency Programs • Two Free Clinics for the Uninsured • Two Article 31 Mental Health Sites
IFH AT A GLANCE Sidney Hillman Walton Urban Horizons Westchester Mount Hope Parkchester
IFH AT A GLANCE New Paltz Kingston Ellenville Hyde Park
Staff and Budget • Over 600 staff members: • family physicians • family nurse practitioners • psychiatrists • social workers • health educators • nurses • practice administrators • administrative staff • A budget of approximately 45 million dollars
Electronic Health Records • State-of–the-art electronic health records and practice management system across all sites • Patient-centered care • MyChart/MyHealth • Continuous quality improvement/research
OTHER HIT COLLABORATIVE EFFORTS • INVOLVEMENT WITH THREE REGIONAL RHIOS (NYCLIX, BRONX, MID-HUDSON) • IMMUNIZATION REGISTRY INTERFACE • LEAD REGISTRY INTERFACE • VISITING NURSING SERVICE INTERFACE • OUTBOUND REFERRALS IN TESTING. • RYAN WHITE REPORTING WITH OUTBOUND EMR DATA REPORTING
Research & IRB • Clinical and health services research supports our core mission to provide access to superior care for all • Supports community-based participatory research • The Institute’s Institutional Review Board (IRB) is a peer-review body responsible for safeguarding the rights of human subjects
Health Information Technology National Recognition • Health Information Management System Society – 2006 Physician’s IT Leadership Award • Health Information Management System Society – 2007 Davies Public Health Award • CDC Center of Excellence in Public Health Informatics with NYC DOHMH and Columbia University • NYCDOHMH Syndromic Surveillance
Syndromic Surveillance • How does it work ? • NYCDOMH receives hundreds of thousands of bits of non-patient identifying data from ER’s, Pharmacies on a nightly basis. • Data includes temperature data, ICDM’s, CPT codes, chief complaints, pharmaceuticals. • Data is power analyzed to determine epidemics earlier than would be possible from laboratoory isolates. • IFH was the first and is still the only ambulatory care site to submit data for this program.
ELECTRONIC DECISION SUPPORT • What influenced us to aggressively implement Electronic Decision Support Alerts ? • Need for making the most of the artificial intelligence inherent in the EHR. • Avoid having a “glorified” paper record. • Effective real-time monitoring available via crystal reporting.
ELECTRONIC DECISION SUPPORT • What were the risks involved with aggressive implementation of Electronic Decision Support Alerts ? • No previous trailblazer organizations that had done this. • Risk of provider alert fatigue – “too many alerts.” • Multiple journal articles dismissing the idea that electronic alerts could improve performance. • Risk of providers not reaching optimal levels in other aspects of EHR documentation.
ELECTRONIC DECISION SUPPORT • What were the factors that led to our aggressive implementation of Electronic Decision Support Alerts ? • Unanimous buy-in by senior leadership. • Groundwork for cooperation was laid by many years of close involvement by site medical directors in the CQI process and clinical policy guidelines development. • Relatively small size of our organization and also the single specialty make-up contributed to being able to quickly make strategic decisions. • Analysis of Pre-EHR QI Studies revealed that interventions that worked the best were those that facilitated documentation by providers
IFH BEST PRACTICE ALERTS PRIMARILY BASED ON HEDIS CRITERIA PNEUMOVAX SEASONAL FLUVAX BREAST CANCER SCREENING CERVICAL CANCER SCREENING LEAD SCREENING HGBA1C TESTING AND CONTROL
IFH BEST PRACTICE ALERTS OPHTHALMOLOGY CONSULTS FOR DIABETICS PEAK FLOW MEASUREMENTS FOR ALL ASTHMATICS NEPHROLOGY CONSULTS FOR PATIENTS WITH GREATER THAN 1.8 SERUM CREATININE LDL SCREENING ANNUAL RPR SCREENING IN HIV
DID THEY WORK ? Initial concern about the introduction of best practice alerts (BPA’s) replaced by enthusiasm for the improvement seen in multiple clinical areas once initial reports showed improvement. Keys to Success-Making sure that the BPA’s were accurate in capturing services rendered (e.g. There are dozens of CPT codes utilized for Cervical Cancer screening)
PROVIDER ACCEPTANCE OF ELECTRONIC DECISION SUPPORT • MORE LIKELY TO ACCEPT ALERTS THAT ARE SIMPLE, LINKED TO EVIDENCE BASED GUIDELINES AND LINK DIRECTLY TO ORDER SETS. • BREAST CANCER SCREENING, CERVICAL CANCER SCREENING AND COLON CANCER SCREENING ARE THE BPA’S CONSIDERED MOST HELPFUL AT IFH.
BPA installed February 2006 N= 183 N= 186 N= 142 N= 140
COLORECTAL CANCER SCREENING All sites listed were fully on the EHR as of Jan 2003
Depression Screening CQI • Electronic Decision Support • Electronic Best Practice Alerts targeted to intake nursing personnel to administer initial depression screening utilizing PHQ-2 screening tool. Initial site targeted Was Parkchester (PKFP) in May 2005. • Positive PHQ-2’s lead to patients filling out PHQ-9’s and then going over the results with their providers. • PHQ-2 administration is captured via reporting. • PHQ-9 results are loaded into the EHR as laboratory type results and are then captured via reporting
Results • There was a statistically significant increase (p<0.0001, Chi2 = 273.6) in Depression Screening Rate at our initial target site, Parkchester from 22% to 79% within one year. • All adult patients at Parkchester are currently being screened at a 90% rate.
Results • Increases in screening rates have also led to increases in the number of visits coded for depression at Parkchester. • There was a statistically significant increase in the % of total visits for adults 19 and over where an ICDM code for depression was used from 4% in 2003 to 17% in the first four months of 2008. (p<0.001).
Results • Increased resources for handling patients with depression came through adding on-site social work therapy and psychiatry support.
Results • Increased % of adult (19 and above) PKFP visits involved the ordering of antidepressants. • Among primary care providers, a statisitcally significant increase from 1.4% to 2.0% has been noted from 2003 to 2007 at PKFP. (P value = 0.002) • 3.9% of PKFP visits between January and April 2008 involved the ordering of antidepressants.
Results • Rate of completing full PHQ-9’S at the same visit after a positive PHQ 2 has been identified has improved from 78% in 2003 to 89% in 2008, but is not at the 100% target goal yet.
Results • The % of patients who went through Depression reassessment and who ended up having PHQ Depression scores < 10 has not changed measurably since 2005.
Next Steps • An attempt to start Phase II spread amongst all other sites in January 2008 did not fair well. Additional administrative and nursing re-orientation was needed. All sites as of July 1, 2008 are now engaged in phase II spread.
Next Steps • Ensure Phase II Spread is successful via a coordinated administrative and clinical effort. • Improved 3 month Positive PHQ-9 Reassessment Rate is needed via social work outreach. Low rate of reassessment is linked to timely follow-up. • Further analysis needed of patients whose PHQ-9 scores fail to improve. Medication Management vs. Access to and Utilization of Mental Health Care. • More detailed reporting needed to track depression outcomes
LINEAR REGRESSION OF AVG HBA1c SCORE VS REFERRAL TO NUTRITION
