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.orgCambridge, Massachussetts

August 20, 2008

EHR IMPACT ON QUALITY PROCESS

MEASURES AND

POPULATION HEALTH IMPROVEMENTS

IFH AT A GLANCEIFH AT A GLANCE

IFH AT A GLANCEIFH 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 GLANCEIFH AT A GLANCESidney Hillman Walton Urban Horizons

Parkchester Mount Hope Westchester

IFH AT A GLANCEIFH AT A GLANCENew Paltz Kingston

Hyde Park Ellenville

Staff and BudgetStaff 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 RecordsElectronic 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 OTHER HIT COLLABORATIVE EFFORTSCOLLABORATIVE 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 & IRBResearch & 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 TechnologyHealth Information TechnologyNational 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 SurveillanceSyndromic 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.

Syndromic SurveillanceSyndromic Surveillance

ELECTRONIC DECISION SUPPORTELECTRONIC 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 SUPPORTELECTRONIC 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 SUPPORTELECTRONIC 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 ALERTSIFH 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 ALERTSIFH 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 ?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 PROVIDER ACCEPTANCE OF ELECTRONIC DECISION ELECTRONIC DECISION

SUPPORTSUPPORT

• 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.

PNEUMOVAXPNEUMOVAXPNEUMOVAX GIVEN PER AGE GROUP VISIT

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

BPA INSTALLED 10/2003

LEAD TESTING LEAD TESTING IN TWO YEAR OLDSIN TWO YEAR OLDS

65%79% 82%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2003 2004 2005

% COMPLIANCE WITH LEAD TESTING

% COMPLIANCEWITH LEADTESTING

37%43%

74%

99%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

April 2003 - July 2004 April 2004 - July 2005 April 2005 - July 2006 April 2006 - July 2007

URBAN HORIZONS URBAN HORIZONS URBAN HORIZONS URBAN HORIZONS

PPD Screening of HIV PatientsUrban Horizons 15 Month Reports

BPA installed February 2006

N= 183N= 186N= 142N= 140

COLORECTAL CANCER SCREENINGCOLORECTAL CANCER SCREENING

Colorectal Screening IFH Sites 2005 to 2008

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

EAST 13TH ST. FAMILY HLTH CTR

MT. HOPE FAMILY HEALTH CENTER

PARKCHESTER FAMILY HLTH CTR

PHILLIPS FAMILY PRACTICE

SIDNEY HILLMAN FAMILY HLTH CTR

URBAN HORIZONS FAMILY HLTH CTR

WALTON FAMILY HEALTH CTR

BPA FOR COLORECTAL SCREENING INITIATED JAN 2008

All sites listed were fully on the EHR as of Jan 2003

Depression Screening CQIDepression 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

ResultsResults

• 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.

PARKCHESTER DEPRESSION SCREENING RATE

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PARKCHESTER

NURSING

PERSONNEL SHORTAGE

NURSING SHORTAGE RESOLVED

STEPPED UP VIGILANCE TO BPA ADHERENCE

DEPRESSION SCREENING RATES AT IFH

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

DEPRESSIONSCREENING RATEFOR NON PKFP IFHSITES

DEPRESSIONSCREENING RATEFOR PKFP

ResultsResults

• 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).

PARKCHESTER % TOTALS VISITS FOR DEPRESSION

4% 5%

17%

11%9%8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 2004 2005 2006 2007 2008

PARKCHESTER% TOTALSVISITS FOR DEPRESSION

% OF TOTAL VISITS WITH DEPRESSION ICDM CODES

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 2004 2005 2006 2007 2008

ALL IFH SITES

PARKCHESTER

ResultsResults

• Increased resources for handling patients with depression came through adding on-site social work therapy and psychiatry support.

0

200

400

600

800

1000

1200

1400

2003 2004 2005 2006 2007 2008 PROJ

PARKCHESTER ANNUAL VISITS FOR DEPRESSION

SOCIAL WORKER

PRIMARY CARE PROVIDER

PSYCHIATRIST

ResultsResults

• 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.

% OF PARKCHESTER VISITS WHERE AN ANTIDEPRESSANT WAS ORDERED

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

% PCP AND PSYCHVISITS WHERE ANANTIDEPRESSANTWAS ORDERED

% PCP VISITSWHERE ANANTIDEPRESSANTWAS ORDERED

ResultsResults

• 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.

PARKCHESTER Rate of patients with phq9 done after a positive phq2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rate of patients with phq 9 done after a positive phq2

ResultsResults

• The % of patients who went through Depression reassessment and who ended up having PHQ Depression scores < 10 has not changed measurably since 2005.

Depression Score OutcomesDepression Score OutcomesMost recent PHQ < 10

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PARKCHESTER

Next StepsNext 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 StepsNext 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

DIABETIC ROLLING 12 MONTH DIABETIC ROLLING 12 MONTH AVERAGE REPORTSAVERAGE REPORTS

2000

2500

3000

3500

4000

4500

5000

Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06

Number DM Patients in Registry

DIABETIC ROLLING 12 MONTH DIABETIC ROLLING 12 MONTH AVERAGE REPORTSAVERAGE REPORTS

ROLLING 12 MONTH AVERAGE OF PERCENT OF HBA1C LESS THAN 7.5

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

55.00%

60.00%

65.00%

Jan-04Mar-04

May-04Jul-04

Sep-04Nov-04

Jan-05Mar-05

May-05Jul-05

Sep-05Nov-05

Jan-06Mar-06

percent of all HbA1c less than7.5

Linear (percent of all HbA1cless than 7.5)

Average HbA1c for DM Patients

7.757.73

7.7 7.69 7.7 7.71 7.72

7.69

7.66

7.61 7.6 7.6 7.67.62 7.62

7.64

7.61

7.58 7.597.617.62

7.74

7.637.647.64

7.697.69

7.58

7

7.1

7.2

7.3

7.4

7.5

7.6

7.7

7.8

Jan-04

Mar-04

May-04

Jul-04

Sep-04

Nov-04

Jan-05

Mar-05

May-05

Jul-05

Sep-05

Nov-05

Jan-06

Mar-06

Average HbA1c for DM Patients

Linear (Average HbA1c for DM Patients)

% OF DIABETIC PATIENTS % OF DIABETIC PATIENTS WITH AN ANNUAL LDL TESTWITH AN ANNUAL LDL TEST

Percent of DM Patients with an Annual LDL Test

66.1%

62.7%

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06

Percent of DM Patients with an annual LDL test

Linear (Percent of DM Patients with an annual LDL test)

Percent of DM Patients with Percent of DM Patients with Ophthalmology Consult OrdersOphthalmology Consult Orders

Percent of DM Patients with Ophthalmology Consult Orders (12 months)

62.9%

46.5%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06

Percent of DM Patientswith OphthalmologyConsult orders (12months)

Linear (Percent of DMPatients withOphthalmology Consultorders (12 months))

LINEAR REGRESSION OF AVG LINEAR REGRESSION OF AVG HBA1c SCORE VS REFERRAL TO HBA1c SCORE VS REFERRAL TO

NUTRITIONNUTRITIONXY AVG MOST RECENT HBA1C SCORE VS REFERRAL TO NUTRITION

6.00

6.50

7.00

7.50

8.00

8.50

9.00

9.50

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

RATE OF REFERRAL TO NUTRITION

AV

G H

BA

1C

SC

OR

E

AVG MOST RECENT HBA1C SCORE(01/05 TO 01/06)

Linear (AVG MOST RECENT HBA1CSCORE (01/05 TO 01/06))

DIABETES BEST PRACTICE DIABETES BEST PRACTICE ALERT SCREENSHOTALERT SCREENSHOT

DIABETES SMARTSET DIABETES SMARTSET SCREENSHOTSCREENSHOT

DIABETES SMARTSET SCREENSHOTDIABETES SMARTSET SCREENSHOT

DIABETES SELF MANAGEMENT TOOL DIABETES SELF MANAGEMENT TOOL SCREENSHOTSCREENSHOT

ELECTRONIC PATIENT ELECTRONIC PATIENT OUTREACHOUTREACH

• 2.0 FTE Outreach/CQI support personnel

• Initially funded by the great gains received from managed care pay for performance incentives

• Now also funded in part by grants for various projects.

ELECTRONIC PATIENT ELECTRONIC PATIENT OUTREACHOUTREACH

• Telephonic and Mail Outreach are done to 20,000 plus patients per year.

TYPES OF OUTREACH

• Targeted outreach based on internal reporting data.• Outreach based on mid-year QARR eligible reports• Outreach to patients assigned to our practices that

have never accessed care.• Outreach to patients who are no-shows for their

specialty appointments/procedures.

ELECTRONIC PATIENT ELECTRONIC PATIENT OUTREACHOUTREACH

Major new grant funded CQI outreach effort in 2008 will involve utilizing risk scores for various types of cancer and targeting cancer screening outreach on a risk adjusted basis.

LAST_VISIT_DATE AGE AGE_SCORE LAST_TOBAC tobacco score BMI

BMI_SCORE

ALCOHOL_OZ_PE

R_WK

ALCOHOL_SCORE

_SCORE

zzzzzz11 8/13/2007 79 6 Quit 1 31.74 2 4.9 1 10

zzzzzz12 8/6/2007 81 6 Quit 1 32.05 2 1.5 - 2 1 10

zzzzzz13 8/15/2007 72 6 Yes 1 42.93 2 3 1 10

CQI BEYOND ELECTRONIC CQI BEYOND ELECTRONIC DECISION SUPPORTDECISION SUPPORT

• Clinical measures reach nadir point.• CQI efforts now refocused on clinical and

operational areas that impact patient care. • Overall goal = Total Quality Management by

getting all functional areas and clinical sites involved in local active CQI

• “Back To The Basics” – Re-examining workflow processes.

CQI BEYOND ELECTRONIC CQI BEYOND ELECTRONIC DECISION SUPPORTDECISION SUPPORT

Information Technology

Information Technology

Local Clinical SitesLocal Clinical Sites

AdministrativeAdministrative

Local Clinical SitesLocal Clinical Sites

FinancialFinancial

Local Clinical SitesLocal Clinical Sites

OperationalOperational

Local Clinical SitesLocal Clinical Sites

TOTAL QUALITY

MANAGEMENT

TOTAL QUALITY

MANAGEMENT