# Presentation: 296448

## The NYC Primary Care Information ProjectA Model for Improving Quality in Small Practices?

- Farzad Mostashari, MD, MSc_[fmostash@health.nyc.gov](mailto:fmostash@health.nyc.gov)__[www.nyc.gov/pcip](http://www.nyc.gov/pcip)_

## Background

- Medical care and clinical preventive services increasingly important to population health
- Medical care not structured to deliver public health benefit, particularly in small practices
- How can we make a structural change?

## Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of Preventive Services to Older Adults by Primary Care Physicians. JAMA. 2005; 294:473-481.

**Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of Preventive Services to Older Adults by Primary Care Physicians. *****JAMA.***** 2005; 294:473-481.**

## * Model controls for practice size, years in practice, hours a week in direct patient care, salary status, physician type (primary care vs. specialist), certification status in specialty, and use of EMR.

**Audet AMJ, Doty MM, Shamasdin J, Schoenbaum SC. Measure, Learn, And Improve: Physicians’ Involvement In Quality Improvement. *****Health Affairs.***** 2005; 24: 843-853.**

**Robert Wood Johnson Foundation. Health information technology in the United States: the information base for progress. **_[http://www.rwjf.org/files/publications/other/EHRReport0609.pdf](http://www.rwjf.org/files/publications/other/EHRReport0609.pdf)__._

## * p<0.05

*** ****p<0.05**

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## Slide 7

## Quality of Care With and Without EHR Use

**Tobacco cessation**

**Statin Use**

**No Benzo in Depression**

***Arch Intern Med.***** 2007;167:1400-1405. **

## Health Care

**That Maximizes Health**

**ELECTRONIC HEALTH RECORDS**
** ****oriented toward *****prevention***

**PAYMENT**
**that rewards *****disease***** *****prevention***** and effective chronic disease management**

**CARE MANAGEMENT**
**and practice workflows to support *****prevention***

- *Frieden TR, Mostashari F. JAMA. 2008 Feb 27;299(8):950-2.

## Primary Care Information Project

- Mission
- Increase the quality of care in medically underserved areas through health information technology (HIT)
- Resources
- NYC: $27 million and 40 staff
- NYS: $11 million
- Feds: $5 million

**Notes:**
Vision:
To improve population health through appropriate health information technology and health information exchange.
Program Areas:
eRx Expansion
EHR Adoption
Health Information Exchange 

## 8 Key Features of the TCNY Build

**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

**2**

**3**

**4**

**5**

**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

**6**

**1**

**7**

**8**

**MEASURE REPORTS**
- Side-by-side provider comparisons of performance on quality measures

## Dr. Bear wants to find out how he is performing compared to other physicians in his practice in controlling high blood pressure for his patients. 

- Dr. Bear wants to find out how he is performing compared to other physicians in his practice in controlling high blood pressure for his patients.

- Using the **QUALITY MEASURE REPORTS FUNCTION, **Dr. Bear is inspired by the performance of his peers in managing the blood pressure (BP) of their hypertensive patients; only one-third of his hypertensive patients have achieved good BP control.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health  |

## Dr. Bear wants to improve his score on BP control and queries the EHR to identify patients with poorly controlled hypertension 

- Dr. Bear wants to improve his score on BP control and queries the EHR to identify patients with poorly controlled hypertension

- Using the **ENHANCED REGISTRY FUNCTION, **Dr. Bear identifies five patients with high blood pressure who do not have an appointment scheduled, and reaches out to each patient; he generates a letter scheduling a follow-up visit with patient Jane Doe.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health  |

## Jane’s blood pressure is elevated (150/90) and highlighted in red by the AUTOMATIC VISUAL ALERT FUNCTION. Dr. Bear can trend her BP over time.

-  Jane Doe receives the letter and makes a f/u appointment
-  During the visit, Dr. Bear’s assistant takes her history and vitals
-  Jane mentions that she has had a few weeks of excessive thirst and fatigue

- Jane’s blood pressure is elevated (150/90) and highlighted in red by the **AUTOMATIC VISUAL ALERT FUNCTION**. Dr. Bear can trend her BP over time.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health |

## Based on Jane’s new diagnosis of diabetes, the CLINICAL DECISION SUPPORT FUNCTION identifies four preventive care services that should be performed.  This list of services is automatically populated in the CDSS panel.

-  Based on Jane’s chief complaint of excessive thirst, Dr. Bear performs a fingerstick test and confirms his suspicion that Jane has diabetes
-  Dr. Bear enters a diagnosis of diabetes into the EHR

- Based on Jane’s new diagnosis of diabetes, the **CLINICAL DECISION SUPPORT FUNCTION** identifies four preventive care services that should be performed.  This list of services is automatically populated in the CDSS panel.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health |

## Dr. Bear uses the QUICK ORDER FUNCTION to order an HbA1C test for Jane, as well as a flu vaccine; the alerts disappear from the panel once they are ordered.  Dr. Bear may also choose to suppress alerts, if he deems them unnecessary. 

- Dr. Bear agrees that these tests are appropriate and should be performed

- Dr. Bear uses the **QUICK ORDER FUNCTION **to order an HbA1C test for Jane, as well as a flu vaccine; the alerts disappear from the panel once they are ordered.  Dr. Bear may also choose to suppress alerts, if he deems them unnecessary.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health  |

## The 1st part of the COMPREHENSIVE ORDER SET displays a selected list of recommended medications (brand & generic) for lipid control. 

- Dr. Bear also selects the “LDL control (high risk)” alert, which displays the order set for high LDL levels

- The 1st part of the **COMPREHENSIVE ORDER SET **displays a selected list of recommended medications (brand & generic) for lipid control.** **

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health |

## The 2nd part of the COMPREHENSIVE ORDER SET displays a selection of recommended labs, immunizations, follow-up appointments, referrals as well as printable physician and patient education materials.  

- Dr. Bear views other order sets for high LDL levels

- The 2nd part of the **COMPREHENSIVE ORDER SET**** **displays a selection of recommended labs, immunizations, follow-up appointments, referrals as well as printable physician and patient education materials.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health |

## Since Jane is a Medicaid patient, Dr. Bear can use the eMedNY FUNCTION to view her 90-day medication history.  He notices that Jane has not filled her lipid medication (simvastatin) for the past three months; she admits that she has stopped taking them because she wondered if her tiredness might have been due to these pills.

-  Dr. Bear wonders   if he should change Jane’s medication regimen to better control her lipids and wants know what medications have been filled by her in the past 90 days
-  Jane has signed a consent form to give the provider access to her medication history

- Since Jane is a Medicaid patient, Dr. Bear can use the **eMedNY FUNCTION **to view her 90-day medication history.  He notices that Jane has not filled her lipid medication (simvastatin) for the past three months; she admits that she has stopped taking them because she wondered if her tiredness might have been due to these pills.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health |

## Tim’s information has already been automatically uploaded to the CITYWIDE IMMUNIZATION REGISTRY.  The CIR will maintain a complete record of Tim’s immunizations which can be accessed by other providers as needed.

-  While she’s there, Jane asks Dr. Bear for a school health form for her 5 year-old (Tim) who is entering day care.
-  Dr. Bear generates a preloaded NYC School Health form populated with Tim’s information for Jane to take with her.

- Tim’s information has already been automatically uploaded to the **CITYWIDE IMMUNIZATION REGISTRY**.  The CIR will maintain a complete record of Tim’s immunizations which can be accessed by other providers as needed.

| 1. Measure Reports | 2. Enhanced Registry | 3. Automatic Visual Alerts | 4. CDSS |
| --- | --- | --- | --- |
| 5. Quick Orders | 6. Comprehensive Order Sets | 7. eMedNY | 8. CIR and School Health |

**Tim**

**male**

**01/01/03**

**Mother**

## EHR Extension- Where to Start?Community Health Centers

- All NYC Community Health Centers to have EHRs by 2009
- 648 providers
- 500,000 patients
- 50% Medicaid, 20% uninsured
- $3.2 million HEAL-NY 1 state grant
- Up to $5.6 million City Capital match
- Up to $9 million CHC match
- New EHRs, or preventive functionality in existing EHRs (n=4)

## EHR Extension- Other Practices

- Focus on small practices
- Deliver 85% of primary care
- Lowest EHR adoption rates
- Greatest challenges in quality and financing
- Need convening and support
- Medical Societies
- QIO (IPRO)
- Hospitals
- Health plans

## Eligibility/ Commitment
Primary Care
Underserved populations (30% Medicaid, uninsured)
Quality Measure Reporting (summarized, confidential)
Financial Commitment
Hardware and Internet
$4k per provider QI fund

PCIP Package
Licenses to TCNY Build of eClinicalWorks
On-site training
Common interfaces
2 years software maintenance and support ($1500/yr) 

- Primary Care
- Underserved populations (30% Medicaid, uninsured)
- Quality Measure Reporting (summarized, confidential)
- Financial Commitment
- Hardware and Internet
- $4k per provider QI fund
- PCIP Package
- Licenses to TCNY Build of eClinicalWorks
- On-site training
- Common interfaces
- 2 years software maintenance and support ($1500/yr)

- Participating Practices

## Small Practice Implementation Lessons

- It’s harder than you think
- Not just early adopters
- Lack of resources
- IT Hardware and Support
- Unreliable internet connections
- Functional interoperability not easy to come by
- Lab interfaces requested 	 In place
- 			Lab A	85	 	4
- 			Lab B	70	 	6
- 			Lab C	38	 	2
- Quality Improvement experience/ culture can be lacking

## Slide 25

## Panel Management Planning Who, What, When, How

- Who is responsible for generating registry reports? Measure reports? Who will oversee this process?
- What action will be taken for each type of reports?
- When will staff make phone calls or generate letters for follow-up?
- How will it be incorporated into workflows?

## Return on Investment to Providers?

## Medical Home Certification

- Practices would
- Fully adopt and utilize TCNY build of eCW
- Complete quality improvement curriculum organized around PCMH domains
- DOHMH would
- Generate summarized EHR utilization reports pertaining to PCMH criteria
- Oversee quality improvement/ technical assistance
- NCQA would
-  Facilitate PCMH designation for PCIP practices

## EHR-Based Recognition and Incentive Programs 

**Clinical-based **quality measures
**Fully transparent** methodologies and systems
**New EHR tools** (CDSS, registry functions, etc.)
**Harmonize measures **used for P4P

**EHR-based P4P Program**

**EHR users**

- BTE

- TCNY-QRS

- Aggregator

- Summary measures

- Patient data

- Summary measures

- Payers

- DOHMH

- Pseudonimized summary measures

- Scorecards

- Incentives/ Recognition

- Scorecards

**1**

**2**

**3**

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**5**

**6**

## Thanks!

| Sam Amirfar
Pamela Anderson
Richard Bordowitz
Mike Buck
Kelvin Chan
Gerald Cohen
Samantha Deleon
Erica Desai 
Nancy Goh
Michael Graziano
George Hripcsak
Melinda Jenkins
Kathryn LaSorsa
Armine Lulejian
Mat Kendall
Brian La Forgia
Ed Lavelle |
| --- |

**Joslyn Levy**
**Lourdes Marte**
**Farzad Mostashari**
**Victoria Njoku**
**Amanda Parsons**
**Jenia Pevzner**
**Kowsilliya Ramnaresh**
**Laura Rosas**
**Reena Samantaray**
**Robert Sanders**
**Kate Shanks**
**Jesse Singer**
**Mytri Singh**
**Andrew Snyder**
**Fiona Somers**
**Nicholas Soulakis**
**Remle Stubbs-Dame**
**Siu-Kwan Tsui**
**Sal Volpe**

- _[www.nyc.gov/pcip](http://www.nyc.gov/pcip)__ _