Moving EHRs Upstream: Lessons from Bronx-CATCH Earle C. Chambers, PhD, MPH Arthur Blank, PhD Peter Selwyn, MD, MPH Department of Family and Social Medicine.

Moving EHRs Upstream: Lessons from Bronx-CATCH

Earle C. Chambers, PhD, MPHArthur Blank, PhDPeter Selwyn, MD, MPH

Department of Family and Social MedicineAlbert Einstein College of Medicine-Montefiore Medical Center

June 2015 ROCChe Meeting

Presenter Disclosures

1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Earle C. Chambers, PhD, MPH

“No relationships to disclose”

Objectives• To describe the background and rationale for the formation of a

multi-stakeholder partnership between medical, public health, and community-based institutions to improve the health of communities in the Bronx, NY (‘Bronx-CATCH’)

• To describe key initiatives to be undertaken by this partnership particularly new data collected via EHR and geographic mapping

• To present selected baseline and preliminary data

• To describe challenges and successes

• To share plans for the future

The Bronx

Bronx, N.Y.:

- Ranked last or near-last in health indicators of 62 counties in NY State in “County Health Rankings” report*

- Population = 1.4million

- poorest urban county in U.S.

*Source: http://www.countyhealthrankings.org/sites/default/files/states/CHR2012_NY.pdf

Current situation - Medical Centers

Medical centers have traditionally focused on improvements in patient care

Medical centers have not focused on the health of the population

New developments including ACO’s and increasing capitation are aligned with goals of population health

Current situation – Department of Health

DOHMH increasingly taking on a “policy, systems, environment” approach

DOHMH has interest and expertise in population-level interventions specifically for clinical practices

The need is there: no paradigm, structures or sustained support currently exists for systematically linking work done “inside” the medical center/clinic to the environment/neighborhood outside

Opportunity

Community and local environmental change pertaining to nutrition, physical activity, and healthy behaviors can have major impact on health outcomes, both for patients and the broader population

Combined clinical and public/population health data sources can support more relevant analysis/evaluation of community health improvement efforts

Bronx-CATCH (“Collective Action to Transform Community Health”) Mission and Strategy

Mission: To create a high-level partnership between health care, public health, community-based organizations and other stakeholders, with the goal of improving the health of local communities throughout the Bronx.

Strategy:

Locally specific interventions

Stakeholder partnerships

Mixed-methods analytic plan

“Health Promotion Zones”

Located in neighborhoods served by FQHC’s or similar local primary care centers

Making the work accountable: Choose important health outcome(s) for which

environment/systems/policy changes are likely or are proven to make a difference

Develop viable metric(s) Develop accountability structure Provide adequate support

Healthy Promotion Zones

Family Health Center

Comprehensive Health Care Center

Via Verde Family Practice

Williamsbridge Family Practice

West Farms Family Practice

South Bronx Health Center

Bronx-CATCH Partners, Target Areasand InterventionsPartners: Montefiore Medical Center, NYCDHMH, BCHN, Northeast Bronx Community-Clergy Coalition, housing and senior centers, youth after-school centers, local schools, Bronx River Alliance, Bronx Borough President, local elected officials, et al.

Areas of Disease Focus• Obesity/diabetes• Hypertension/cardiovascular disease• Cancer

Areas of Planned Community Intervention• Food access and nutrition• Fitness and physical activity• Smoking cessation and prevention

Strategic goal: to develop locally specific intervention plans which are also generalizable, across the many touch-points of the health care delivery system and the wider community.

Data already collected and available in EHR:

• Race or Ethnicity• Preferred Language• Depression – PHQ2 and PHQ9• Tobacco Use• Residential Address• Census Tract-level US Census data e.g. median income

Data added to EHR through CATCH:• Physical Activity

• Dietary Patterns

Added expertise:• Geocoding

• Geographic mapping

• Geographic Information System Analysis

Community Health Survey (CHS)

16

18+ years old

17

13 to 17 years old

18

6 to 12 years old

1) Clinical staff bypassing the survey questions -Skipping some questions -Bypassing the survey altogether

2) Technical glitches with the EHR form- ‘random’ popup of survey

Problems with Year 2 EHR Survey data

SuccessesChallenges• Provider fatigue regarding

questionnaire

• Developing useful feedback to clinicians

• Developing tracking mechanisms within EHR

• Evaluation of workflow

• Evaluation of specific intervention elements

• No dedicated staff to oversee data collection, management, analysis, and feedback

• Change in hospital priorities over time + no extra funding

• Change in EHR system (EPIC)

• Partnership with local organizations/stakeholders

• Incorporation of CHS questions into EHR + trainings

• Extraction of EHR data + comparison to neighborhood level data

• Implementation of interventions with preliminary evaluations underway

Partnership with local organizations/stakeholders• Getting buy-in from Health Department and medical directors at

clinic sites helps convince hospital management of importance of measures.

• DOH runs CHS training sessions at clinics

Incorporation of CHS questions into EHR + trainings• Communication with IT Department regarding design of data

collection within the EHR (when to administer, how to bypass if necessary, etc)

• Consistent testing of validity of data to ensure that accurate data is being collected (drop down menu vs. write-in fields)

• Identifying who will ask questions and training of those staff in how to access questions in EHR and ask them correctly to patients

Extraction of EHR data + comparison to neighborhood level data• Are we able to get data out on the back end in a format that is

easily analyzed using our statistical software packages? • What are neighborhoods?

What did it take?

Data content director EHIT

Data Dumps EHIT

Flow of EHR RISK ASSESSMENT data regarding CHS questionnaire items

Data Manager EHIT

Data extractor EMR-CHS

Spatial analyst EHR-CHS

Earle ChambersDirector of EMR-CHS OCH site coordinator of EHR directives

OCH Senior Team

OCH sites

DOH-CHS training OCH site coordinator

Director of community outreach

Data extractor- Sybase

DOH

Earle ChambersDirector of EHR-CHS

Office of Community Health –OCH Data Oversight

What are the results?

Walked or biked more than 10 blocks in past 30 days, 2013

0

10

20

30

40

50

60

70

80

90

100

54.2 55.7 57.5 58.8 59.667.4

80.3 80.3 78.8 80.3 80.3 78.2

Health Center UHF neighborhood

Percenta

ge r

espondin

g ‘Y

es’

Note. Data source for UHF neighborhood estimates: 2012 Community Health Survey, NYC Department of Health and Mental HygieneᴬData collection from July to December 2013; ᴮData collection from January to December 2013.

(Percentage responses to CHS/EHR Questions for Adults Aged 18 and Over)

Participation in physical activity/exercise

during past 30 days, 2013

0

10

20

30

40

50

60

70

80

90

100

62.4 62.5 64.4 66.1 68.274.3

80.571.2 71.2 71.2 71.2

82.0


Percenta

ge r

espondin

g ‘Y

es’



No servings of fruit and vegetables eaten yesterday, 2013

0

10

20

30

40

50

60

70

80

90

100

29.1 31.4 26.6 26.9 28.823.018.0 18.0 18.0 23.0 18.0 20.8


Percenta

ge r

espondin

g n

one



One or more sugary drinks consumed on average per day, 2013

0

10

20

30

40

50

60

70

80

90

100

53.4 48.3 48.342.5 41.1

33.341.4 41.4 41.4 37.1 41.4 39.8


Percenta

ge r

espondin

g 1

or m

ore



• Collaborate with other Montefiore departments where work and expertise can be shared.

• Office of Community and Population Health • Institute for Clinical and Translational Research (ICTR)

Biomedical Research Informatics Core• Clinical IT Research and Development

• Continue to build research agenda to guide data collection and broader dissemination of results

• Analysis of first several sites’ experience will inform plans to expand program model to other clinical/community locations.

• Revisit metrics and revise based on new priorities and timeframe (population comparisons, repeated measures)

• Use geographic mapping to identify high risk areas (hotspots) where interventions can be targeted

Where do we go from here?

Continue to link primary care and population health using evidence based medicine

YDPP Form in EHR

Referral form in EHR

• Offered to pre-diabetic patients at local sites

• Referral incorporated into EHR

• Follow-up with YDPP program staff

YDPP Referral Program

© 2015 MLP | Boston

Samantha Morton, JD Executive Director

MLP | Boston

CHI Impact of SBP Data Collection: Perspectives from the Boston Medical

Center Department of Pediatrics’ Utility Shut-Off Protection Campaign

Moving EHRs Upstream AAMC ROCChe Virtual Meeting

June 18, 2015


MLP | Boston

We equip healthcare, public health and social services teams with legal problem-solving strategies that promote health equity for vulnerable people:

•Capacity-building (trainings, toolkits)•Legal “Triage” (rapid access to consultation)•Legal “Surgery” (panel of 20+ law firm/in-house partners)•Technical assistance re: SDOH systems re-design and policy change


Key History

•Founded in BMC Pediatrics in 1993

•Became independent in 2012

•Gave rise to National Center for MLP, now sited at GWU Milken Institute School of Public Health www.medical-legalpartnership.org

– Medical Director = Megan Sandel, MD, MPH (BMC), who also serves as Principal Investigator for Children’s HealthWatch

•Recent HRSA classification of civil legal aid as an “enabling service” for CHCs

http://www.medical-legalpartnership.og/


Dana-Farber Cancer Institute

Hallmark Health System

MA Department of Public Health

Metro North Regional Employment Board

Mount Auburn Hospital

Steward Health Care System

Good Samaritan Medical Center

Saint Anne’s Hospital

Boston Medical Center

(Geriatrics, OB-GYN, Pediatrics,

Women’s Health/Oncology)

The Children’s Trust /

Healthy Families Massachusetts

Current Partners


Why Try to Improve ProviderEngagement with Patient Requests for

Utility Shut-off Protection Letters?


This was not a typical screening gap

• High volume of requests for medical certifications absent systematic provider screening mechanism

• Disconnects between patient, provider, and systems

– Harms to patient-families (losing heat and lights, related health impacts, e.g., sickle cell crises)

– Work flow challenges, role confusion for providers

– Negative impacts on provider-patient relationship


Designing a thoughtful intervention

• Buy-in from critical hospital stakeholders–Boston Medical Center Grow Clinic, Food Pantry–Children’s Health Watch –Pediatric Primary Care

• Effective leadership, including:–JoseAlberto Betances, MD–Megan Sandel, MD, MPH

“When you have a large urban clinic like ours that sees more than 24,000 families―most of whom will qualify for government protections for low-income families―you just

have a huge volume of families who need this,” explained Dr. JoseAlberto Betances at the time.


“If my low-income patients with chronic disease are forced to make difficult budget choices,

the last thing I want is for them to worry about whether their power is going to stay on.

Shut-off protection is one way I know I can help a parent who’s struggling to meet his or her families’ living needs.”

― Dr. Megan Sandel


The Intervention (2006-08)

• Training by MLP | Boston advocates–Addressed various screening strategies–Included hosting of “Utilities Awareness Weeks”–Development of Utility First-Aid Kit and related model Utility Access Policy for the institution

• Integration of Shut-off Protection Letter template and related guidance on EHR–“Horses” – more readily resolvable by provider team–“Zebras” – referred to MLP | Boston “Energy Clinic” for more intensive evaluation

• Ability to connect patients with complex utility service problems to advocacy as needed


Impacts: Patient Level

• 2005-06: BMC Pediatrics signed 193 shut-off protection letters

• By 2007, BMC Pediatrics was generating 80% more such letters for patient-families

• In 2008-09, Department generated 676 such letters – a 350% increase from baseline


Impacts: Provider Level

• Better understanding of context in which patients make these letter requests, and the role providers are expected to play under current public policy

• Improved work flow – centralized access to templates and related forms on EHR

• Data-driven engagement with the issue, including ability to track letter generation via EHR


Impacts: Population Level

• Learning from this campaign synergized with a timely MA DPU (Department of Public Utilities) review of its regulations

• We engaged intensively with regulatory review process– supplied expert, joint medical-legal testimony citing data from this

effort that informed regulatory changes adopted in late 2008 – developed strategic alliances with National Consumer Law Center

and Action for Boston Community Development in this process

• Patients-to-Policy trajectory was realized, helping thousands of low-income patient-families across the state better meet their energy needs


Ensuing State-Wide Policy Change

• Onerous re-certification process for patients and providers

relaxed illness re-certification requirements for many categories of ill patients

• Absence of protections for key vulnerable populations

new eligibility for households with infants and adults 65+

• Antiquated understanding of healthcare actors (MD only)

now MDs, NPs, and PAs may sign letters


Data, Policy, and CHI: A Key Lesson

• At the policy level, the medical voice was influential. In its written explanation of the changes, the DPU cited the joint medical-legal comments:

–In D.P.U. 08 4, the Department heard testimony that loss of utility service is hazardous to the health of children. D.P.U. 08 4 (Medical-Legal Partnership | Boston Initial Comments at 1).

–In D.P.U. 08 4, the Department heard testimony that allowing only a registered physician or local board of health official to certify and renew the certification of a serious illness, combined with the frequency that renewals are required, has created a significant backlog in medical offices. D.P.U. 08 4 (Medical-Legal Partnership | Boston Comments at B).


Positive Sequelae

• Ongoing innovation and research at BMC re: how best to connect patients with “concrete supports” like utility service

• Project DULCE

–Robert Sege, MD, Ph.D et al. Medical-legal strategies to Improve Infant Heallthcare: A Randomized Trial. Pediatrics (July 2015) (published on-line June 1, 2015)–Intervention = Family Specialist backed by MLP | Boston and Healthy Steps–Faster access to concrete supports (including utility service), lower ED utilization, better rates of on-time preventive care and immunizations

• Other innovative health equity research underway with MLP | Boston via BMC Pediatrics/Addiction Medicine, OB-GYN, and Women’s Health/Oncology


Active MLP | Boston Health Equity Research Participation with BMC

• Addiction Medicine / Pediatrics / OB-GYN– Evaluating MLP-backed Family Specialist intervention for

women in methadone-assisted treatment with infants (PI = Ruth Rose-Jacobs, Sc.D)

• Women’s Health/Cancer Care– Contrasting standard patient navigation services for newly

diagnosed cancer patients with MLP-backed patient navigation for the same population (PI = Tracy Battaglia, MD, MPH)

• OB-GYN– Contrasting standard of care for pregnant women

confronting a high degree of social risks with an MLP-backed birth coach model for the same population (PI = Julie Mottl-Santiago, CNM, MPH)

• All in RCT (randomized controlled trial) context


References

• Megan Sandel, et al. The MLP Vital Sign: Assessing and Managing Legal Needs in the Healthcare Setting. Journal of Legal Medicine, Vol. 35, Issue 1 (2014): 41-56.

• Megan Sandel, et al. Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations. Health Affairs 29, No. 9 (2010): 1697-1705.

• Utility Access and Health: A Medical-Legal Partnership Patients-to-Policy Case Study (2010). Joint publication of the National Center for Medical-Legal Partnership and Medical-Legal Partnership | Boston, available at http://www.mlpboston.org/results/mlp-boston-publications

http://www.mlpboston.org/results/mlp-boston-publications

http://www.mlpboston.org/results/mlp-boston-publications


Thank you . . .

. . . for thinking deeply about research efforts that will meaningfully acknowledge The Whole

Patient and improve health equity!


Copyright Statement

This presentation is for educational purposes only; nothing in it should be construed as legal advice.

MLP | Boston permits copying, redistribution and adaptation of this presentation, in whole or in part, provided that (a) you notify MLP | Boston at [email protected] prior to copying, redistributing, or adapting the presentation; and (b) any copy, redistribution or adaptation 1) retains the copyright notice that appears at the bottom of each slide, 2) retains this statement, and 3) attributes the presentation, or the portion used, to “MLP | Boston.”

Moving EHRs Upstream: Lessons from Bronx-CATCH Earle C. Chambers, PhD, MPH Arthur Blank, PhD Peter Selwyn, MD, MPH Department of Family and Social Medicine.

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