Institute of Medicine:Linking EHRs to

Public Health Departments

Michael Buck, PhDDirector of Biomedical Informatics

mbuck@health.nyc.govApril 8, 2014

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Actionable Information in NYC:Primary Care Information Project (PCIP)

Mission

• Improve quality of care in medically underserved areas through health information technology

• “Clinical Action Arm” bureau of the NYC Department of Health and Mental Hygiene

• Promote new models of care focusing on prevention and public health priorities

• Develop new tools in population health management

• Transition providers from paper charts to an EHR

Success

• Over 12,000 providers joined PCIP and the Regional Extension Center (NYC REACH), including more than:• 1095 independent practices

• 63 community health centers

• 54 hospitals & outpatient clinics

• Millions of patients

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Data

• We receive eClinicalWorks EHR data on 3000 providers, caring for ~1.8 M patients per year, ~350,000 encounters per month, data on 5M+ patients since 2009

• Using Medicaid claims data – to analyze and create dashboards to reach non-eClinicalWorks providers

• Commercial claims data

Information

• We turn raw data into usable, targeted, actionable information and use it to drive public health focused interventions

Action

• Dashboards: over 20,000 sent last year

• On-site QI: over 4,000 site visits last year

• PCMH: PCIP sites are 439 out of 1051 total sites in NYS (42%)

• Pay for Quality Programs: Health eHearts, Health eQuits

• Community Engagement activities

Data -> Information -> Action

Infrastructure to Retrieve EHR Data:The Hub Population Health Network

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“The Hub” allows secure exchange of aggregate data with PCIP practices on the eClinicalWorks EHR Send out queries Receive patient counts

overnight The Hub currently covers:

• 700+ practices• ~1.8 M patients per year• 5 M+ patients since 2009

Buck MD, Anane S, Taverna J, Amirfar S, Stubbs-Dame R, Singer J. The Hub Population Health System: Distributed Ad Hoc Queries and Alerts. J Am Med Inform Assoc. Published Online First: 9 November 2011. doi:10.1136/amiajnl-2011-000322.

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>100

80,000 60,000 40,000 20,000 0 20,000 40,000 60,000 80,000

Hub 2012 Population Pyramid

MaleFemale

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Patient Care-seeking Behaviorby Borough

Ambulatory ILI Syndromic Surveillance during 2009 H1N1

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f Inf

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ike-

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isits

Feedback to Providers

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Proposal: Develop and validate best practices for using data from EHRs for population health surveillance.

In partnership with CUNY School of Public Health, the NYC Health Department will create EHR-based estimates and compare them to a “gold standard” 2013 local HANES survey. We will select high performing measures as the basis of the NYC Macroscope EHR surveillance system.

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The NYC Macroscope Project

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Gold Standard:NYC HANES 2013

• Partnership with CUNY SPH

• Representative sample of 1,500 randomly selected New Yorker adults

— Household-based sampling

— Citywide estimation

• Detailed health interviews (CAPI, ACASI)

• Brief physical exam

• Biological specimen collection (blood, urine)

• Mental health screening

2002 2003 2004 2005 2006 2007 2008 2009 20100

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Obesity Among NYC Adults as Measured by the Com-munity Health Survey, NYC HANES and the PCIP Hub

% Obese(BMI ≥ 30)

Year

First NYC HANES

PCIP Hub

Community Health Sur-vey

Adults ages 20 and over. Data are age-adjusted to the U.S. standard 2000 population. For more information about the CHS or the 2004 NYC HANES, please see www.nyc.gov/health/epiquery

EHR Limitations: Bias and Measurement Error

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National ONC Standard:Query Health

• Completed federal initiative to build distributed query capabilities across healthcare IT vendors.

• http://wiki.siframework.org/Query+Health

• New York City/State Depts. of Health completed one of the first pilots of this new national standard across HIE and EHR data sources.

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CCDA-basedData Model

Develop modular, testable portfolio of Query Health standards and specifications that can adopted by the industry, and support key HITECH and govt. priorities

Standardize Privacy and

Security

Reference Implementation

Services

Vocabularies: SNOMED-CT, LOINC,

RxNorm

i2b2

The ResultsNew QRDA 2 & 3

PopMedNet

Query Health Standards and Reference Implementation Stack

Reference Implementation

Stack

The QuestionNew HQMF

Query EnvelopePrivacy Policy Enablement

hQueryStandardize

Services

Standardize Meaning

Standardize Structure

Sharing Value Sets

Klann JG, Buck MD, Brown J, Hadley M, Elmore R, Weber GM, Murphy SN. Query Health: standards-based, cross-platform population health surveillance. J Am Med Inform Assoc. Published Online First: 4 April 2014. doi:10.1136/amiajnl-2014-002707

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NYS DOH

NYC PCIP

Information Requestors Data Sources

Hospital

Practice

Sends Query to HIE

New York Population Health RegistryStage 2 Meaningful Use Proposal

Statewide HIECCDA

Repository(SHIN-NY)

Other

Returns Aggregate Results

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Literature1. Klann JG, Buck MD, Brown J, Hadley M, Elmore R, Weber GM, Murphy SN. Query Health: standards-based, cross-

platform population health surveillance. J Am Med Inform Assoc. Published Online First: 4 April 2014. doi:10.1136/amiajnl-2014-002707

2. Kaye K1, Singer J, Newton-Dame R, Shih SC. Health information technology and the primary care information project. Am J Public Health. 2014 Mar;104(3):e8-9. [Epub 2014 Jan 16].

3. Wang JJ, Sebek KM, McCullough CM, Amirfar SJ, Parsons AS, Singer J, Shih SC. Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems. Prev Chronic Dis. 2013 Aug 1;10:E130.

4. Andrew M. Ryan, Tara F. Bishop, Sarah Shih and Lawrence P. Casalino. Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records. Health Affairs, 32, no.1 (2013):53-62

5. DeLeon SF, Pauls L, Shih SC, Cannell T, Wang JJ. Early Assessment of Health Care Utilization Among a Workforce Population With Access to Primary Care Practices With Electronic Health Records. J Ambul Care Manage. 2013 Jul-Sep;36(3):260-8.

6. Begum R, Smith Ryan M, Winther CH, Wang JJ, Bardach NS, Parsons AH, Shih SC, Dudley RA. Small Practices’ Experience with EHR, Quality Measurement, and Incentives. Am J Manag Care 2013;19(11 Spec No. 10):eSP12-eSP18.

7. Bardach NS, Wang JJ, DeLeon SF, Shih SC, Boscardin WF, Goldman LE, Dudley RA. Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: A randomized trial. JAMA. 2013;310(10):1051-1059.

8. Ancker JS; Singh MP; Thomas R; Edwards A; Snyder A; Kashyap A; Kaushal R. Predictors of success for electronic health record implementation in small physician practices. Appl Clin Inform. 2013 Jan 16;4(1):12-24.

9. Ryan AM, Bishop T,Shih S, Casalino LP. Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records. Health Aff (Millwood). 2013 Jan;32(1):53-62.

10. Buck MD, Anane S, Taverna J, Amirfar S, Stubbs-Dame R, Singer J. The Hub Population Health System: Distributed Ad Hoc Queries and Alerts. J Am Med Inform Assoc. Published Online First: 9 November 2011. doi:10.1136/amiajnl-2011-000322.

11. Plagianos MG, Wu WY, McCullough C, Paladini M, Lurio J, Buck MD. Syndromic surveillance during pandemic (H1N1) 2009 outbreak, New York, New York, USA. Emerg Infect Dis 2011; 17:1724-6. http://wwwnc.cdc.gov/eid/article/17/9/pdfs/10-1357.pdf. Accessed October 5, 2011.

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Contact Information

Michael Buck, PhDDirector of Biomedical Informaticsmbuck@health.nyc.gov