Transcript Subject Matter Expert Meeting Tobacco Control

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
[email protected]
www.nyc.gov/pcip
Agenda
•
•
•
•
PCIP Background
The New Federal HIT Agenda
The PCIP Approach to EHR Adoption
Open Discussion
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 American Smokers trying to quit that
gets help – 20%
Percentage of American GDP spent on health care – 15 %!!
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
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
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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 Immunizations You Need
Make Your Home Safe and Healthy
Have a Healthy Baby
HEALTH
INFORMATION
SYSTEMS
that are oriented toward
prevention
Health Care
that Maximizes Health
REDESIGNED
PRACTICE
WORKFLOWS
PATIENT ENGAGEMENT
that highlights prevention
PAYMENT
that rewards disease
prevention and the
effective management of
chronic disease
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 datadriven, citywide quality
improvement efforts, all focused
on preventing heart attacks and
strokes.
The New York City
Primary Care Information Project
• 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)
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
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 collection in the March 2009 issue of
Health Affairs
2
3
1.
2.
3.
Mostashari, F., M. Tripathi, Kendall, M. (2009). "A Tale Of Two Large Community Electronic Health Record Extension Projects." Health
Affairs 28(2): 345-356.
Diamond, C. C., F. Mostashari, et al. (2009). "Collecting And Sharing Data For Population Health: A New Paradigm." Health Affairs 28(2):
454-466.
David Blumenthal, The Federal Role in Promoting Health Information Technology, The Commonwealth Fund, January 2009
The Challenge……
Delivery of ambulatory care in
the US by size of practice1
Adoption of HIT in Physician
Practices, by size2
38
1-2 physicians
6-10 physicians
8
1
15
44
Percentage
> 11 physicians
27
22
15
11
32
3-5 physicians
1
2-5
6-15
16-30 > 30
Number of physicians in a practice
When It Comes to Prevention, there Is
Room for Improvement
Proportion of Medicare Beneficiaries Receiving
Recommended Preventive Services, by Practice Size
Pneumococcal
Vaccination
**
**
Influenza Vaccination
Solo/2-person (1-2)
Small group (3-10)
Colon Cancer
Screening
Medium/large group (11+)
**
***
Mammograms
Hemoglobin A1c
Monitoring
***
Eye Examinations for
Diabetics
*
0
10
20
30
40
50
60
70
80
90
100
Proportion of Medicare Beneficiaries Receiving Preventive Care, %
* P<.05
** P<.01
*** P<.001
Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of Preventive Services to Older Adults by Primary Care Physicians. JAMA. 2005; 294:473-481.
Most Providers Lack Quality Improvement Tools
Multivariate Analyses: Effects Of Practice Size On Access To
Practice-Level And Quality-Of-Care Data, Physicians’ Ability
To Generate Quality-Of-Care Data Internally, And Physicians’
Involvement In Redesign Efforts, 2003
Involved in redesign
efforts (n=1,744)
Quality-of-care data
internally generated
(n=1,705)
Solo (1)e
Small (2-9)
Midsize (10-49)
Large (50 or more)
Access to any qualityof-care data (n=1,757)
Access to any
practice-level data
(n=1,757)
0
10
20
30
40
50
60
Proportion of Physicians, %
70
80
90
100
*
* 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.
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
1
continuity of care .”
–
David Blumenthal, National Coordinator for Health IT
PCIP = RHITEC
Services Necessary To Support Meaningful EHR Use
1) Accountability 2) Vendor
Selection
3) Development
4) Provider
Outreach/
Education
5) Practice
Readiness
Assessment
6) Project
Management
7) Technology
Support
8) Work Flow
Redesign
9) Interface
Services
10) Training
11) Quality
Reporting
12) Billing
Support
13) EHR
Configuration
14) Patient
Engagement
15) Quality
Improvement
16) Business
Analysis
17) Evaluation
18) Privacy &
Security
19) Enterprisewide Solutions
20)
Communications
1) Accountability
EMAS- PCIP
Aug
2008
Oct
Sep
Nov
Dec
Jan
Feb
Mar
Apr
2009
Jun
May
1. PCIP TCNY eCW EHR provider agreements
Actual
Target
Total Actual
Total Target
119
0
1363
1,200
30
0
1393
1,200
27
0
1420
1,200
89
0
1509
1,200
51
600
1560
1,800
49
0
1,609
1,800
41
0
1,650
1,800
79
0
1,729
1,800
64
0
1,793
1,800
34
131
814
850
945
850
63
250
1008
1,100
83
0
1,091
1,100
20
0
1,111
1,100
18
300
1,129
1,400
118
0
1,247
1,400
3. Percentage of eligible and willing small practices with at least one quality improvement visit
Actual %
59%
55%
57%
69%
82%
75%
Target %
70%
Actual Number of Monthly Visits 29
27
36
41
42
30
103
130
166
207
249
279
Cumulative total of Visits
74%
70%
22
301
72%
70%
31
332
72%
70%
39
371
4. Percentage of eligible and willing small practices with one EMR visit
Actual %
12%
20%
31%
37%
Target %
Actual Number of Monthly Visits 11
13
18
10
11
24
42
52
Cumulative total of Visits
48%
35%
9
87
44%
35%
0
87
44%
40%
5
92
0
0
0
600
1,800
2,400
0
300
1,400
1,700
75%
75%
40%
40%
2. Number of providers using TCNY eCW EHR
Actual
Target
Total Actual
Total Target
86
652
600
128
250
780
850
44%
14
66
45%
35%
12
78
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
3) EHR Development - Highlights
QUALITY REPORTS
1
Compares provider performance on
quality measures to citywide averages
QUICK ORDERS
5
COMPREHENSIVE ORDER SETS
ENHANCED REGISTRY
2
Identifies patients through structured
data elements (e.g., diagnoses, drugs,
labs, demographics)
6
highlights abnormal vitals
7
CDSS
4
Automatically displays preventive
service alerts that disappear once
addressed
Displays best practice
recommendations (e.g., for meds, labs,
patient education)
eMedNY
AUTOMATIC VISUAL ALERTS
3
Allows one-click ordering of
recommended preventive services
With patient consent, displays 90-day
history of all Rxs filled by Medicaid
patients
CIR and School Health
8
Sends information to City Immunization
Registry and generates school health
forms
4) Provider Outreach/Education
We have secured signed commitments from:
- 1,804 providers in 331 practices, 425 sites*
Practices
Sites
Providers
Hospitals
4
38
614
CHCs
26
72
534
Small
Practices
301
315
656
Total
331
425
1804
- including over half of the 280 eligible small practice
providers located in underserved neighborhoods:
March 2009
August 2008
31
Not In Pipeline
In Pipeline
249
141
139
~ 1 new practice goes live
on the EHR every day
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?
6) Project Management
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
8) Work Flow Redesign
Map
as-is
workflows
Workflow
kick off
meeting
Goals
Deliverables
Week 1
 Identify key
practice staff
who will need
to be involved
in the redesign
process and
set the
workflow
schedule
Workflow
schedule
defined.
 Staff named
for all required
roles.

Weeks 2-3
 Understand
current highlevel
processes that
will be
impacted by
the EHR.
Identify
reports and
other
information
that must be
tracked in the
EHR

As-is
flowcharts for
high-level
processes
 Examples of
all key
documents and
reports that will
need to be in
the system

Train
Super
Users
Week 4
 Learn basic
functions,
workflow, and
reporting ability
of eCW.
 Understand
how certain
procedures are
typically
performed in
eCW.
Revise
practice
workflows
to eCW
Configure
eCW
Test
workflows
Weeks 5-6
 Reassess
high level
processes and
determine how
they will be
altered through
the adoption of
the EHR.
Weeks 6-8
 Configure the
system to meet
practicespecific
operational
and clinical
policies and
procedures
Weeks 9-10
 Ensure
revised
practice
workflows can
be successfully
adapted to
site-specific
staffing and
procedures.
 Identify
 Load
how
staff roles will
change
 Identify
required points
of configuration
Mapping of
data elements
from key
reports/forms
to existing data
elements in
eCW.
 Staff posttraining “hot
seat” test
results

 New
eCWenabled
flowcharts
 List of new
staff EHR
functions
 List of
specific
configuration
needed in the
system
information into
the EHR that
will allow for
successful
billing and
other
transactions
 Sucessful
testing of the
new EHR
processes
Design
training
materials
& agenda
Week 11-12
 Provide staff
with tools that
can assist
them in
completing
new tasks.
 Ensure
that
site hardware
has been
properly placed
training
agenda with
eCW and
prepare
practicespecific
elements
 Sign

off on
adapted
workflows and
configuration
by Process
Owners
Update
practice
policies &
procedures
Post-golive
 Ensure the
practice’s policy
and procedures
reflect the new
EHR-enabled
policies and
procedures
 Plan
“Cheat
sheets” for
specific
processes
 Final
attendee lists
for training
sessions
submitted to
eCW
 Documentation
codifying the
EHR-enabled
polices and
procedures
 New job
descriptions for
staff
9) Interface Services
Lab Implementation Progress ( 6- month recap)
# of Interfaces Live
165
127
125
100
82
85
60
53
45
37
16
7
27
18
22
23
5
Jul-08
Aug-08
Sep-08
Oct-08
Months
Nov-08
Dec-08
Cumulative Interface Total
Interfaces Live by Month
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
TRAINING AGENDA
Training Session: EMR Plus
Duration: 8:30am-12:30pm (4 hrs)
Description
Come ask an eCW trainer any system question!
At EMR Plus, providers set the agenda and drive the learning curve.
Trade best practices with peers who have adopted the eCW EHR.
Suggested topics include creation, use and modification of:

Templates

Order Sets

Flow sheets

Smart Forms
Additional areas of exploration include:

Lab workflow post interface

Progress note customization

User settings

Privacy and Security
11) Quality Reporting
Draft Practice Results: ABCS and Comparison to NYC Average
A
B
Aspirin
100%
100%
80%
80%
75%
73%
71%
69%
60%
60%
40%
35%
42%
40%
37%
40%
PRACTICE XYZ
0%
Q1
Q2
Q3
NYC
57%
59%
50%
51%
53%
54%
PRACTICE XYZ
Q1
Q4
S
Cholesterol Control (Overall)
Q2
NYC
Q3
Q4
74%
77%
Smoking Cessation
100%
74%
85%
81%
78%
80%
70%
72%
60%
60%
40%
55%
0%
100%
80%
53%
20%
20%
C
Blood Pressure Control (Overall)
40%
42%
41%
44%
20%
20%
PRACTICE XYZ
0%
Q1
Q2
Q3
# eligible pts
469
# pts met goal
# pts missed goal
Quality Measures
324
145
Aspirin
NYC
21%
9%
PRACTICE XYZ
Q1
38
84
206
21
50
195
17
34
BP Control in HTN Patients
BP<140/90
in general
population
34%
0%
Q4
401
46%
40%
BP<130/80
in pts with
DM
BP<140/90
in pts with
IVD
197
Q2
93
174
42
23
51
Cholesterol Control
TC<240 or
LDL<160 in
general pop’n
LDL<100
in pts with
IVD or DM
Your practice has saved ### lives
Q3
80
7
73
Smoking
Cessation
NYC
Q4
12) Billing Support, 13) EHR
Configuration 14) Patient
Engagement
DCO-ON0056-20090404-njPP1
CLIENT-FACING TEAMS ARE PHASED IN, AS APPROPRIATE
Small Practice Consulting Approach
eCW project management
... eCW account management
PCIP implementation management ...
PCIP integration management
Printed
PCIP Billing consulting
Small practice
consulting
Working Draft - Last Modified 4/3/2009 7:03:42 PM
PCIP Outreach
PCIP EMR consulting
PCIP QI consulting
Panel Management
Patient engagement
PCIP Pay for Quality
Primary Care Information Project |
15) Quality Improvement
BP Control- By Practice
100.00
80.00
April 2009
60.00
40.00
20.00
0.00
0.00
20.00
40.00
60.00
80.00
100.00
Jan 2009
Preliminary QI data for PCIP practices showing
improvement in BP control from January 2009 to April
2009 for most practices
16) Business Analysis
PCIP has launched a pilot incentive program (eHearts) to reward providers for delivering
excellent preventive care for cardiovascular health
High risk
Core Quality
Measures
All Patients
Uninsured/
Medicaid
With Diabetes
Diabetes and
Uninsured/Medicaid
Aspirin
$20
-
-
-
Blood
Pressure
Control
$20
2X
2X
4X
Cholesterol
Control
$20
2X
2X
4X
Smoking
Cessation
$20
-
-
-
•Average Provider can earn between $10,000 to $20,000
•Maximum cap for any practice is $100,000
Example of incentive payment: For a patient with diabetes and who is either Medicaid or uninsured, controlling a
patient’s blood pressure can result in an $80 reward.
17) Evaluation
Practice Essays (N = 130)
0
100
Completed Patient Surveys – Pre-EHR (N = 736, representing 10 sites)
200
300
400
500
60
50
449
Quality of Care
% of
patients
351
Business Function
Access to Better
Data
40
30
20
337
10
192
Patient Experience
0
10
9
8
7
6
5
4
3
2
1
Rating Scale: 1 = worst, 10 = best
Completed Provider Surveys - Pilot Post 6 months (N = 97)
Productivity Analysis before and after EHR (N = 70 providers, 1 site)
% Respondents
0
50
Monitoring Rx
safety
65
Keeping
medication lists
Monitoring Rx
adherence
100
73
36
Post-EHR
% Slightly Easier or Much Easier**
18) Privacy & Security
Encryption
Back Up/Recovery
Audits
Network Security
Access Controls
Physical
Security
Policies and Procedures and
Training
19) Enterprise-wide Solutions
System
Administrator
Manage users/roles
Update Content
Add Content
Content
administrator
C
L
I
E
N
T
Common Content Manager
core
lab
insurance
Service
Interfaces
S
e
r
v
i
c
e
B
u
s
Core Functionality
authentication
security
web services
authorization
persistence
user interface
auditing
scheduler
pluggable
Submit content
Client
Content
Providers
(labs, insurs.)
Retrieve content
Clinical
System
Receive change
notification
Content
Consumers
20) Communications
• Newsletter
– Bi-monthly
• NYC Users
Conference
– 500+ attendees
• Web 2.0 social
networking site
– Facilitate data
exchange among
participants
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