The Primary Care Information Project: Helping NYC use HIT for Health Care ABCS

1. The Primary Care Information Project: Helping NYC use HIT for Health Care ABCS Mat Kendall PCIP Director of Operations New York City Department of Health and Mental Hygiene mkendall@health.nyc.gov www.nyc.gov/pcip

2. Agenda • PCIP Background • The New Federal HIT Agenda • The PCIP Approach to EHR Adoption • Open Discussion

3. On ABCS, USA Gets an “F” • Percentage of Americans at increased risk of heart disease that is taking Aspirin – 33% • Percentage of Americans with hypertension that has adequately-controlled Blood pressure – 44% • Percentage of Americans with high Cholesterol that has adequately-controlled hyperlipidemia – 29% • Percentage of AmericanSmokers trying to quit that gets help – 20% Percentage of American GDP spent on health care – 15 %!!

4. Mayor Bloomberg on Health IT “Health information technology….is a potential game-changer. That’s what we’re finding in New York City, where we’ve created the nation’s largest primary care electronic health record network. It links more than 1,100 doctors with more than a million patients in low-income communities with a prevention-focused EHR. … EHRs also allow doctors to actually understand how many patients they’re treating and how well they’re doing in preventing illness.  With that data, EHRs also create the potential to reward doctors for actually keeping people healthy.” - Mayor Bloomberg, “Address to US Conference of Mayors.” March 2009

5. What is the Government’s Role? • To ensure that electronic health record systems address public health priorities. • To use economies of scale to support implementation efforts. • To support quality improvement by promoting and harmonizing quality-linked funding streams. • To help provider groups optimize their EHR configuration and use. Public Health Priorities • Have a Regular Doctor or Other Health Care Provider • Be Tobacco-Free • Keep Your Heart Healthy • Know Your HIV Status • Get Help for Depression • Live Free of Dependence on Alcohol and Drugs • Get Checked for Cancer • Get the ImmunizationsYou Need • Make Your Home Safe and Healthy • Have a Healthy Baby

6. HEALTH INFORMATION SYSTEMS that are oriented toward prevention REDESIGNED PRACTICE WORKFLOWS PAYMENT that rewards diseaseprevention and the effective management of chronic disease PATIENT ENGAGEMENT that highlights prevention Health Care that Maximizes Health

7. NYC’s Vision for Health Care and Health IT • In 2005, Mayor Bloomberg pledged to provide EHRs to 1,000 NYC doctors in underserved neighborhoods. • To date, PCIP has brought over 1,300 high-volume Medicaid providers live on an EHR system customized for prevention; we will reach 3,000 by the end of 2010. • This EHR network has enabled us to launch a pilot pay-for-quality program and to pursue data-driven, citywide quality improvement efforts, all focused on preventing heart attacks and strokes.

8. Mission To increase the quality of care in medically underserved areas through health information technology (HIT) Resources NY City: $30 million (staff, software, hardware, services) City Council: $6 million (CHC infrastructure) Clinic/practice contributions: >$15 million NY State HEAL: $11 million (expansion) Federal: $5 million (research and evaluation) Robin Hood Fund $4-6 million (pay for performance) Wellpoint Foundation $500,000 (additional licenses) The New York CityPrimary Care Information Project

9. Our Model: The Building Blocks of Quality Pt Engagement Team-Based Care Panel Management Pay for Quality Quality Improvement EHR Development and Implementation Strategy and Procurement Vision 2005 2006 2007 2008 2009 2010 2011

11. HIT and the Federal Stimulus Bill • The American Recovery and Reinvestment Act echoes NYC’s investment with $30 billion in health IT incentives contingent on the “meaningful use of EHRs” by providers and hospitals. The bill provides: • $2 billion for the Office of the National Coordinator for HIT to • Foster health information exchange • Develop a national HIT workforce • Extend initial loans for adoption • Provide EHR implementation assistance • Medicaid Incentives for providers (FY 2011) • For physicians with 30% Medicaid or greater (peds 20%) • 85% of Net Allowable Costs • $25,000 upfront (installation, upgrades) • $10,000 annual support x 5yrs if “meaningful use” is demonstrated • Medicare incentives for providers (FY 2011) • Up to $44,000 for meaningful EHR use over five years • PCIP’s success has been highlighted as a model for scaled community EHR adoption and distributed data collection2 in the March 2009 issue of Health Affairs3 • Mostashari, F., M. Tripathi, Kendall, M. (2009). "A Tale Of Two Large Community Electronic Health Record Extension Projects." Health Affairs28(2): 345-356. • Diamond, C. C., F. Mostashari, et al. (2009). "Collecting And Sharing Data For Population Health: A New Paradigm." Health Affairs28(2): 454-466. • David Blumenthal, The Federal Role in Promoting Health Information Technology, The Commonwealth Fund, January 2009

12. The Challenge…… Adoption of HIT in Physician Practices, by size2 Delivery of ambulatory care in the US by size of practice1 > 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

13. When It Comes to Prevention, there Is 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.

14. Most Providers Lack 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.

15. Regional Health Information Technology Extension Centers (RHITEC) • The Recovery Act establishes “regional centers (to) provide technical assistance and disseminate best practices to support and accelerate efforts to adopt, implement, and effectively utilize health information technology.” • RHIREC Criteria • Centers must provide 50% matching funds • Centers must be non-profit organizations “Obtaining real value from unprecedented federal investments will require local support organizations that help doctors install these systems and use them to achieve improved quality, efficiency, and continuity of care1.” • David Blumenthal, National Coordinator for Health IT

16. PCIP = RHITEC

17. 1) Accountability

18. 2) Vendor Selection • Following NYC procurement rules, in January 2006 PCIP submitted an RFP to acquire an EHR solution: • Our focus was on supporting community providers in small practices, community health center (CHC), hospital outpatient departments and correctional environments to successfully adopt an EHR. • The process took 16 months. • We used scale/resources to secure key provisions from our vendor: • We obtained “most favored pricing” • We negotiated to keep Intellectual Property (IP) in the public domain • We successfully tied payment tied to practice utilization of the system • We established an integrated structure for development and deployment: • through securing an array of NYC-based resources • through working closely with the vendor during product development

19. 3) EHR Development - Highlights QUALITY REPORTS Compares provider performance on quality measures to citywide averages QUICK ORDERS Allows one-click ordering of recommended preventive services 5 1 COMPREHENSIVE ORDER SETS Displays best practice recommendations (e.g., for meds, labs, patient education) ENHANCED REGISTRY Identifies patients through structured data elements (e.g., diagnoses, drugs, labs, demographics) 2 6 eMedNY With patient consent, displays 90-day history of all Rxs filled by Medicaid patients AUTOMATIC VISUAL ALERTS highlights abnormal vitals 3 7 CDSS Automatically displays preventive service alerts that disappear once addressed CIR and School Health Sends information to City Immunization Registry and generates school health forms 4 8

20. 4) Provider Outreach/Education We have secured signed commitments from: - 1,804 providers in 331 practices, 425 sites* - including over half of the 280 eligible small practice providers located in underserved neighborhoods: ~ 1 new practice goes live on the EHR every day

21. 5) Practice Readiness Assessment Leadership & Vision Is leadership committed? How informed and involved are clinical staff? Are there clinic-level champions? Are patients being engaged in the initiative? Organizational Planning Has the CHC established measurable goals for HIT adoption? Does it typically budget for IT? Has it estimated ongoing costs likely to accompany adoption? Policies & Procedures Does the CHC have formal policies for clinical, business, and administrative practices that support HIT implementation? Is HIT use built into HR tasks and standards? Staff Capacity Are end-users computer proficient? Can the CHC identify a multidisciplinary project management team? Will IT staff resources be adequate? Technical Capacity Is there adequate bandwidth? Are there contingency plans for network failure? What additional hardware/software will be required?

22. 6) Project Management

23. 7) Technology Support • IT Assessments • PCIP staff interview each practice and discuss deployment strategies, such as ASP vs. client hosting of the application • Leveraging City Purchasing Power • PCIP has devoted $6 million to procuring a core set of IT equipment for providers located in medically underserved areas • IT Vendor Assistance • PCIP maintains a list of IT vendors who can support practices with basic day-to-day IT needs • We’re exploring the option of providing expanded support services in the form of help desk assistance

24. 8) Work Flow Redesign

25. 9) Interface Services

26. 10) Training • On-site Training • Basic EHR training (source of CME credit) • Advanced training for clinical decision support tools • Off-site Training • Basic and advanced topics • Web Training • Web work sessions

27. 11) 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)

28. 12) Billing Support, 13) EHR Configuration 14) Patient Engagement SmallPractice ConsultingApproach

29. 15) Quality Improvement Preliminary QI data for PCIP practices showing improvement in BP control from January 2009 to April 2009 for most practices

30. 16) Business Analysis PCIP has launched a pilot incentive program (eHearts) 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

31. 17) Evaluation Practice Essays (N = 130) Completed Patient Surveys – Pre-EHR (N = 736, representing 10 sites) Completed Provider Surveys - Pilot Post 6 months (N = 97) Productivity Analysis before and after EHR (N = 70 providers, 1 site)

32. 18) Privacy & Security Encryption Back Up/Recovery Audits Network Security Access Controls Physical Security Policies and Procedures and Training

33. 19) Enterprise-wide Solutions

34. 20) Communications • Newsletter • Bi-monthly • NYC Users Conference • 500+ attendees • Web 2.0 social networking site • Facilitate data exchange among participants

35. PCIP Summary We brings the Bloomberg approach of data-driven decision-making to health care We seek to equip providers with exactly the information they need, exactly when they need it We employ this data-driven approach internally, using metrics to keep focus and enforce accountability We are an implementation success story and a high-profile national model for HIT initiatives We are changing health care delivery in NYC We are well-positioned to use federal payments Uncertainties exist, but there are many paths to sustainability after 2011