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Making the Most of Electronic Health Records: A Framework

for EHR-Enhanced Quality Improvement

Joslyn Levy, BSN, MPHDirector, Clinical Systems Improvement

Bureau of Chronic Disease Prevention & ControlNew York City Department of Health and Mental Hygiene

jlevy@health.nyc.gov

Children's Health FundJuly 10, 2007

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Clinical Systems Improvement Activities

• Improve chronic care management – Disseminate educational materials and tools to support the

management of key chronic conditions

• Promote adoption of improvement methods and chronic disease prevention and management strategies– Provide onsite coaching

• Promote adoption of disease registries and reporting systems

• Promote knowledge transfer and sharing between participating practices– Convene collaborative learning forums on chronic conditions

management• Address topics such as evidence-based practice and self-management

support

• Link practices to community resources and NYC DOHMH initiatives

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Clinical Systems Improvement Timeline

NYC Childhood Asthma and Preventive Services Collaborative

2001 – 2002 21 Peds and FP practices

Public Health DetailingColonoscopy, flu vaccine, smoking cessation, asthma, diabetes, hypertension, cholesterol, contraception, depression screening, HIV testing, alcohol screening, electronic health records

2002 - present 236 practices (DPHO)

4066 practices (citywide)

NYC Diabetes and Depression Collaborative 2003 - 2004 23 IM and FP practices

NYC Diabetes Collaborative – Phase II Spread 2005 - present 3 Institutions

Preventive Services Advisors 2005 - present 8 IM and FP practices

Chronic Disease Training Institute

- Self management goal setting-Nutrition

2006 - present 25 practices

60 + trainings

900 + people trained

Primary Care Information Project 2006 – present 6 Institutions

Clinician’s Toolbox & Self-management Program (Physicians Foundation)

2007 - present Start-up phase

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Primary Care Information Project

• Mission– Increase the quality of care in medically underserved areas

through health information technology (HIT)

• PCIP Roadmap– Citywide EHR Network – Citywide Quality Improvement Network– Citywide Health Information Exchange Network

• Key Priorities– Safety net providers’ IT Infrastructure – Building population health into EHRs– Learning how to achieve QI with EHRs– Sustainability- “pay for …”

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Medical Home

• Care is coordinated & comprehensive• Care is planned, monitored and measured• Community based PCPs are active co-

managers with specialists • Children and their families are supported as

partners in care• Community resources are integrated into

care and community cultures are supported• Clinics and practices offer phone and easy

office access

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QI Principles Supported by eCW• Give the right care at the right time

– Point of care reminders– Quality dashboard– Evidence-based treatment options for TCNY measures– Linkages to Public Health Information Systems (CIR)

• Everyone gets the care that they need (population management)– Actionable care opportunity reports

• Performance feedback is credible and timely– Primary caregiver (responsible party) clearly identified– Reports based on current clinical data– Flexible query function for drilling down into a measure– Citywide data available for benchmarking

• Care is reliable, coordinated and efficient– Standardized workflow– Clinical practice expectations clear– Administrative tracking systems

• Patients are partners in care– Integrated self-management support– Patients/families provide feedback on the care they receive

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eCW Characteristics That Support QI

• Role-based treatment screens• Structured data collection• Field for primary caregiver • Clinical decision support system (CDSS)• Registry• Integrated self-management support• Performance feedback reporting• Administrative tracking systems

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Role-Based Screens

• Clearly delineate “what needs to be done when and by whom” and diminish room for error and omission

• Facilitate all staff members working to the maximum capacity of their licensure and “frontloading” care

• Underscore the importance of the care team

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Structured Data Collection• What

– Entering patient information in a specific field that is only for that piece of information.

• Why– Structured data entry makes it possible to retrieve

data when you need it and makes it possible to generate reports easily. When structured data elements are entered in narrative section only, data element will not be counted in report.

• Examples: – Multiple peak flow readings during one visit.

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Primary Caregiver

Provider who provides continuing care of varied medicalconditions, not limited by cause, organ system, or diagnosis

eCW has three provider fields• PCP (Insurance-related provider)• Primary caregiver (responsible/accountable provider)• Rendering provider (provider who takes care of the patient at that

encounter)

All registry and performance feedback reports will be generated basedon primary caregiver.

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Clinical Decision Support System (CDSS)

Asthma Examples

• Point of care reminders (alerts, dashboard, highlighting, etc.)– Severity assessment required– Persistent asthma classification consider inhaled corticosteroid– Smoking cessation counseling recommended

• Interactive forms and order sets – Severity assessment calculator– Asthma orders (e.g. prescribe appropriate meds, asthma action

plan, education, referral for specialty care, spirometry)• Care opportunity reports (actionable)

– Patients overdue for planned care visits– Patients who will need a flu shot

• Performance feedback reports– % of patients with severity assessment by practice site– % of patients with persistent asthma with ICS prescribed by

provider

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Registry• What

– A system for collecting and maintaining relevant clinical data for patients to be used to monitor and improve the care of the population

• Why– Anticipate (who will need a flu shot)– Prepare (who is coming in for an asthma planned visit and what will they need

during the visit)– Follow up (who needs follow-up call on their self-management goal)– Recall (who was discharged from hospital and no follow-up visit within 2 weeks)– Stratify (who is in greatest need of outreach and support)

• How– Run standard set of reports on predetermined schedule– Review and formulate recommendations for follow up (e.g., order test, schedule

appt.)– Develop systems for follow-up (phone outreach, mail merges for batched

reminder letters, care management)• Who

– Designated panel manager/care coordinator– Functions delegated to different members of the care team with one individual

responsible for oversight and coordination of registry functions– QI department staff

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Integrated self-management support– Self-management goal setting and follow-up tools– Library of patient education materials in multiple

languages that address varied health literacy & cultural needs

– Fields for tracking teaching methods used and documenting patients/families understanding

– Automated formulary checks by insurance coverage make it easier to ensure that patients get the medications they can most afford

– Structured medication reconciliation with structured documentation for reasons for non-adherence

– Patient/family satisfaction assessment tools– Referral lists for community based organizations– Patient portal for patients to access to their record &

health information and resources

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Performance Feedback• Uses

– Identify systems issues in need of remediation or duplication– Identify variation: learn from top performers & provide support to

providers who may be struggling– Identify areas for focused improvement work– Identify gaps in knowledge and skills– Drive and assess ongoing quality improvement work at the

provider, practice and site levels

• Effective feedback depends on– Clear understanding of what the measures represent– Accuracy of reports – Regular and routine dissemination– Availability of meaningful comparison and benchmark data– The spirit in which feedback is provided– The support that is provided for improvement

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Administrative Tracking Systems

• Care coordination– Referral ordered, not arranged (care coordinator

supports referral in MH)– Referral appointment date at least two weeks ago, no

report received– Consult reports pending by specialty provider or

practice– Consult received, not reviewed

• Access to Care– High priority messages not returned – Visits to primary care provider as a % of total visits– Advanced access scheduling measures

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What Will Make eCW Work as a Quality Improvement Tool?

Pre-implementation

• Careful assessment of current practice followed by workflow redesign for key processes to avoid using a new tool to do everything the old way

• Practice consensus on clinical guidelines and expectations• Knowledge and skills training to address gaps• Clear assignment of responsibility and a plan for producing and using registry

reports• Clear assignment of responsibility and a plan for producing and using

performance feedback reports

Post-implementation

• Consistent use of structured fields for documentation• Accurate primary caregiver assignment• Charting during the patient visit• Follow-through on registry and performance feedback plans• Dedicated time for quality improvement work

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PCIP Partner Practices: Eligibility and Public Purpose

• Care for underserved / vulnerable populations– Medicaid and uninsured– DPHO areas (S Bronx, Harlem, Central Brooklyn)

• Participate in public health goals – Mandatory indicator reporting (automated, confidential)– Quality improvement (inc. decision support tools)– Public health interfaces (school health, CIR)

• Financial Commitment– $4k per provider contribution to QI fund– Assume all ongoing costs after 2 yr testing phase

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What Is Included?

• Licenses to “NYC Build” eClinicalWorks• 2 years maintenance and support (M&S)• Common data interfaces• On-site training • Quality improvement technical assistance

• Predictable, low ongoing M&S costs– Less than $1,500 per FTE provider/ yr

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For further information

Joslyn LevyClinical Systems Improvement

jlevy@health.nyc.gov212-676-2577

Primary Care Information Projectpcip@health.nyc.gov

www.nyc.gov/pcip