Impact of an Electronic Health Record on the Promotion of NIH Asthma Guidelines in the Primary Care Setting Natalie Langston-Davis, MD, MPH Children’s Hospital at Montefiore Residency Program in Social Pediatrics Department of Family & Social Medicine Betty Perez-Rivera, EdD, CHES NYC Department of Health & Mental Hygiene Ariel Sarmiento, MPH Ivette Santana NY Children’s Health Project-Montefiore Medical Center

The Children’s Health Fund Founded in 1987 by pediatrician/child advocate Irwin Redlener, MD and singer/songwriter Paul Simon. Founded in 1987 by pediatrician/child advocate Irwin Redlener, MD and singer/songwriter Paul Simon. Established initially to address the lack of basic and critical health care services available to NYC homeless children and their families and later expanded to reach children and families living in medically underserved communities around the country. Established initially to address the lack of basic and critical health care services available to NYC homeless children and their families and later expanded to reach children and families living in medically underserved communities around the country.

Flagship Programs New York Children’s Health Project (1987) New York Children’s Health Project (1987) South Bronx Center for Children & Families (1993) South Bronx Center for Children & Families (1993)

Asthma—National Facts 17.3 million Americans 17.3 million Americans 5,000 related deaths per year 5,000 related deaths per year A leading cause of school and work absenteeism. A leading cause of school and work absenteeism. Disproportionate effect in low income & minority populations Disproportionate effect in low income & minority populations

Asthma and Children 5 million children in the US 5 million children in the US Prevalence increased by an average of 4.3% per year from 1980 to 1996 Prevalence increased by an average of 4.3% per year from 1980 to % increase/yr in office visits from % increase/yr in office visits from Increased in hospitalizations by 1.4%/yr from Increased in hospitalizations by 1.4%/yr from

Asthma Mortality (per 1,000,000) Among US Children, ( Pediatrics 2002; 110: ) Overall Mortality Race White-NH Black-NH Hispanicn/a**

Prevalence of Asthma in Children Ages, 4-5, NYC-1999 NYC-DOHMH

Hospitalizations--NYC Higher hospitalization rates in children aged 0-14 yrs of age: Higher hospitalization rates in children aged 0-14 yrs of age: –1.8 x higher than the rate in the US –3.4 x the rate in NYS

Hospitalizations, By Borough-2000

NYC Asthma Mortality Rates by Borough, All Ages-1990 & 2000

Childhood Asthma Initiative Childhood Asthma Initiative Established in 1997 to empower families to successfully manage and control their asthma. Established in 1997 to empower families to successfully manage and control their asthma. Three integrated program components include: Three integrated program components include: Target populations are homeless families and families living in medically underserved communities of the South Bronx, NYC. Target populations are homeless families and families living in medically underserved communities of the South Bronx, NYC. CLINICALEDUCATIONALPSYCHOSOCIAL

Asthma Among Homeless Children (Arch of Ped & Adol Med 2004; 158: ) 40% of children in homeless shelters had asthma 40% of children in homeless shelters had asthma Large percentage w/ severe persistent asthma Large percentage w/ severe persistent asthma Many children had inappropriate treatment Many children had inappropriate treatment

NIH-NHLBI Guidelines Developed in 1997, revised 2002Developed in 1997, revised 2002 Emphasis on 4 basic components:Emphasis on 4 basic components: Measure of lung function Measure of lung function Pharmacologic management Pharmacologic management Environmental control Environmental control Patient education Patient education Patient self-management componentPatient self-management component

Barriers to Guideline Use Length Length Complexity Complexity Provider attitudes and perceptions Provider attitudes and perceptions Lack of educational materials and support staff Lack of educational materials and support staff

Modified NIH Guidelines-CAI ER Visits-4 mon, 12 mon ER Visits-4 mon, 12 mon Hospitalizations-4 mon, 12 mon Hospitalizations-4 mon, 12 mon Asthma Severity Asthma Severity –Daytime Symptoms –Nighttime Symptoms Controller Med Use Controller Med Use

PenChart Electronic Health Record Laptop Toughbook Computers— PenTablets Laptop Toughbook Computers— PenTablets Computerized Pages—Templates Computerized Pages—Templates –Well Child Exams –Sick Visits/Follow-up Mandated Assessment Mandated Assessment

Methods Contiguous Time Period Contiguous Time Period Retrospective Chart Review Retrospective Chart Review 200 Patients-SBHCCF 200 Patients-SBHCCF 193 Patients-NYCHP 193 Patients-NYCHP Ages 6 months-19 years Ages 6 months-19 years

VariableNYCHPPre n=97; p <.05 NYCHPPost n=96; p<.05 YesNoYesNo Severity16.5%83.5%83.3%6.7% Control Med 72.2%27.8%87.5%12.5% ER 4 mon? 13.4%86%47.9%52.1% ER 12 mon? 20.6%79.4%45.8%54.2% Hospital 4 mon? 13.4%86.6%45.8%54.2% Hospital 12 mon? 15.5%84.5%44.8%55.2%

VariableSBHCCFPre n=100; p<.05 SBHCCFPost YesNoYesNo Severity16%84%58%42% Control Med 50%50%62%38% ER 4 mon? 6%94%38%62% ER 12 mon? 6%94%39%61% Hospital 4 mon? 8%92%39%61% Hospital 12 mon? 8%92%41%59%

Comparative Rate of Increase-% Change NYCHPSBHCCF Severity Controller ER-4 mon ER-12 mon Hosp-4 mon Hosp-12 mon

Merits of the Electronic Health Record Organized Medical Charting Organized Medical Charting Chronic Disease Management Chronic Disease Management Continuity Among Providers Continuity Among Providers Facilitate Data Collection, Reporting & Research Facilitate Data Collection, Reporting & Research

Study Limitations Assessment of Modified Guidelines Assessment of Modified Guidelines Specialized Population Specialized Population Methods Evaluation—Not Outcomes Methods Evaluation—Not Outcomes

Conclusions Facilitate Physician Use of EBM Algorithms Facilitate Physician Use of EBM Algorithms Chronic Disease Management Chronic Disease Management Standardized Medical Charting Standardized Medical Charting