The Primary Care Information Project

The Primary Care Information Project

Sarah Shih, MPH

Exec. Dir. Healthcare Quality Information

New York City

Department of Health and Mental Hygiene

[email protected]

http://www.nyc.gov/pcip

NYC’s Health Agenda

Take Care New York1. Have a Regular Doctor or

Other Health Care Provider2. Be Tobacco-Free3. Keep Your Heart Healthy4. Know Your HIV Status5. Get Help for Depression6. Live Free of Dependence on

Alcohol and Drugs7. Get Checked for Cancer8. Get the Immunizations You

Need9. Make Your Home Safe and

Healthy10. Have a Healthy Baby

Health Carethat Maximizes Health

HEALTH INFORMATION

SYSTEMS that are oriented toward

prevention

PAYMENTthat rewards disease prevention and the

effective management of chronic disease

REDESIGNED PRACTICE

WORKFLOWS

PATIENT ENGAGEMENTthat highlights prevention

Focused on Medically Underserved Patients in NYC

We have secured signed commitments from2,100 providers in 379 practices and at 480 sites

~ 1 new provider goes live on the EHR every day

Practices Live In Progress

Practice: IS ratio

Small Practices 247 96 86:1

Health Centers 18 13* 15:1

Hospital OPDs 3 2* 4:1

Sub-total 268 111

*Practice with sites both live and in implementation

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BRINGING THE RESOURCES OF LARGE NETWORKS TO INDEPENDENT SMALL PRACTICES - A “VIRTUAL NETWORK”

Kaiser Permanente

NYC PCIP

PCIP, eCW & Practice team structurePCIP eCW Practices

Small LargeImplementation specialists

Project Managers, Business Analysts, SAMs

Providers, Office Managers

Project Management Team

Infrastructure team Technical Specialists IT Consultant IT Department

Interface Coordinator (PM, labs and CIR)

Lab Interface team Providers, Office Managers

IT Department, Ref/In-house lab

Quality Assurance Development team Providers, Office Managers

Site Administrators

Quality Improvement consultants, Super Users, Billing consultants

Trainers, Billing Specialist, Business Analyst

Providers, Office Managers, Biller

Quality Improvement Unit, Financial Dept.

Privacy and Security consultants

Development team Providers, Office Managers

IT Department, Legal

Development team Development team Providers, Office Managers

Super Users

AUTOMATIC VISUAL ALERTS

Highlights abnormal vitals

CDSS

Automatically displays preventive service alerts that are suppressed when

addressed

QUICK ORDERS

One-click ordering of recommended preventive services

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3

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COMPREHENSIVE ORDER SETS

Displays best practice recommendations (e.g., for meds, labs,

patient education)

ENHANCED REGISTRY

Identifies patients by structured data (e.g., diagnoses, drugs, labs,

demographics)

eMedNY

With patient consent, displays 90-day history of all Rxs filled by Medicaid

patients

CIR and School Health

Sends information to City Immunization Registry and generates school health

forms

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MEASURE REPORTS

Side-by-side provider comparisons of performance on quality measures

8 Key Features of the TCNY Build

Small Practice Consulting Approach

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Following Medical Home and Chronic Care ModelsUseful framework for organizing QI work

▪ Actionable curriculum consisting of a collection of discrete activities and achievable goals

▪ Focus on “whole-practice” redesign (e.g. teamlet care – C. Sinsky)

▪ Provide actionable and meaningful feedback

▪ View EHR-derived quality measure data on a routine basis

▪ Provides incremental recognition

“BOOTS ON THE GROUND”

▪ Assist practices through the process and lower the “activation energy”

▪ Software, QI, EMR consulting, Pay for Performance, relationships

▪ Partnership with NCQA- multi-site survey

▪ Keep practices focused on care & and reduce administrative burdens

▪ Average physician spends $68,274 per year interacting with insurance plans*

▪ Focus practices on areas to have the highest impact for health

▪ Provide share resources to practices (care coordinators, nurses, panel managers)

▪ Conduct patient outreach using the data from HER*J. A. Sakowski, J. G. Kahn, R. G. Kronick et al., "Peering into the Black Box: Billing and Insurance Activities in a Medical Group," Health Affairs

Web Exclusive, May 14, 2009, w544–w554

How do we know whether providers are meaningfully using the EHR?

• PCIP staff– Scheduled on-site visits– Demo of registry query functions

• Data Transmissions from EHR– Encounter information from PM– Utilization of EHR metrics– Quality Measures (EoC)

Average Encounters Per Month by Practice Size*

1st3rd

6th

Solo Providers (n = 61)

Two Providers (n = 18)

Three or more Providers (n = 13)

890 9471031

437 500544

233257 317

0

100

200

300

400

500

600

700

800

900

1000

1100

No

. o

f E

nco

un

ters

No. of Months on EHR

*Limited to small practices that have been on the EHR for 6 months or more. Data available on ~116 small practices

PCIP Contractual Expectations with Providers Selected Measures for Demonstrating Use of EHR

1. Visits where office visit CPT codes were entered into the progress note.

2. Visits where an order set was used as part of the progress note.

3. Visits where a smart form was used as part of the progress note.

4. Visits where blood pressure was entered into the progress note.

5. Visits where allergy data was entered in a structured format

6. Insurance claims created over total number of insurances for patients that month

7. Visits where medications were prescribed through the EHR

8. Prescriptions entered into the EHR that were sent via fax or electronic interface

9. Labs reviewed over labs ordered

10.Current medications were entered or verified in the EHR

11.Months in a 6 month period when required data files were transmitted to the DOHMH

12.Months in a 6 month period when all core utilization measures were reported to the DOHMH

Proposed Meaningful Use MeasuresOverlapping with Data Transmitted to PCIP

Line 2011 Measures (Draft from HITECH) Level

9, 10 % of permissible RX's transmitted electronically Provider

21,22% lab results incorporated into EHR in coded format [OP,IP]

Practice Provider

26% of encounters for which clinical summaries were provided [OP, IP] Provider

28% of encounters where med reconciliation was performed [OP, IP] Practice

30Report up-to-date status for childhood immunizations [OP] Practice

31% reportable lab results submitted electronically [IP] Practice

EHR Utilization Transmitted to PCIP

• Snapshot of monthly activities• Number of practices with EHR use data

– 133 practices in July and August 2009– 85 have been using EHR for 8 months or longer

*limited to practices on the EHR for 8 months or longer

EHR use transmissions Total Jul* Total Aug*

Lab results transmitted 48,072 52,183

Lab results reviewed 56,731 63,882

Use of Medicaid State Rx Claims 2,422 2,560

Active patients 508,079 516,283

Proposed Meaningful Use MeasuresCurrently within PCIP Quality Measures

Line 2011 Measures (Draft from HITECH)

1 % diabetics with A1c under control [OP]

2 % of hypertensive patients with BP under control [OP]

3 % of patients with LDL under control [OP]

4 % of smokers offered smoking cessation counseling [OP, IP]

5,6 % of patients with recorded BMI [OP]

14 % of patients over 50 with annual colorectal cancer screenings [OP]

15 % of females over 50 receiving annual mammogram [OP]

16 % of patients at high-risk for cardiac events on aspirin prophylaxis [OP]

17 % of patients with current pneumovax [OP]

19 % eligible patients who received flu vaccine [OP]

Note: Quality Measures are collected at the provider level and stratified by insurance type. For some practices, stratified by race/ethnicity, though few providers are completing the field for race/ethnicity

Preliminary Data – Quality MeasuresMar08 to Feb09 Aug08 to Jul09

Measure Name N Mean (std) Sum* N Mean (std) Sum*

A1C control (< 7%) 12 53.7 (16.6) 492 44 47.2 (17.0) 2,498

Antithrombic Treatment 58 47.5 (21.2) 8,617 89 49.6 (21.3) 13,686

Asthma control (5-11 yrs) 3 87.8 (18.4) 49 4 89.0 (12.4) 104

Asthma control (12-17 yrs) 2 74.1 (16.4) 22 3 90.6 (8.4) 54

Asthma control (18-56 yrs) 2 45.7 (36.4) 12 11 61.9 (27.5) 105

Body Mass Index 86 61.6 (29.8) 83,029 110 70.4 (26.9) 126,842

BP Control ≤130/80 DM 56 23.9 (13.5) 4,922 78 30.7 (17.3) 7,358

BP control ≤140/90 HTN 63 48.6 (16.4) 12,305 85 51.9 (16.0) 18,480

BP Control ≤140/90 IVD 32 67.4 (16.3) 650 46 69.7 (20.1) 868

Cholesterol Control <100 gen pop 14 63.4 (22.5) 573 48 52.2 (21.3) 3,145

Cholesterol Control <100 IVD,DM 15 65.3 (18.5) 874 37 62.4 (15.7) 1,879

Breast cancer screening 16 4.5 (5.8) 6,346 51 5.2 (7.9) 22,034

Colorectal cancer screening 8 1.9 (1.3) 4,126 46 3.9 (6.2) 22,008

Influenza vaccine (over 50) 48 22.6 (18.4) 25,550 70 15.6 (15.2) 38,431

Pneumococcal vaccine 66 9.8 (13.0) 27,352 98 9.8 (13.5) 45,641

Smoking cessation intervention 45 19.0 (14.5) 4,798 79 29.7 (23.6) 8,253

*A population estimate was derived by summing across practice denominators per measure

Questions?

Contact: [email protected]

Visit: http://www.nyc.gov/pcip