County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Watching the Weight of the Community: Use of an IIS for BMI Tracking & Intervention Presented by: Heidi DeGuzman, BSN SDIR Registry Services Coordinator A collaboration of the San Diego Regional Immunization Registry (SDIR), the San Diego County Childhood Obesity Initiative (SD COI) and the Altarum Institute

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Credits SDIR BMI Work Group of the SDCOI Healthcare Domain: – Beth Costello, MBA, Altarum Institute –Anne Cordon, MPH, CHES, SDIR Manager –Philip Nader, MD Professor Emeritus, UCSD –Cheryl Moder, MBA, Director, SD COI –Amy Sheon, MPH, PhD, Childhood Obesity Prevention Mission Project (CHOMP) Co-Director, Altarum Institute Presentation based on pilot work and summary report Data produced by David Kopald, Data Analyst, UCSD Immunization Partnership

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Background Body Mass Index (BMI) reporting capacity added to SDIR June, 2008 Late spring 2009 San Diego County Obesity Initiative formed SDIR BMI workgroup, with technical support from the Altarum Institute In August, 2009, 1 st process review began with one clinic; 2nd and 3 rd clinic reviews started in January and February 2010 Identify needs, barriers, issues and process improvement activities

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Areas of Focus for Work Group SDIR BMI Surveillance Database and SDIR BMI Reporting Tool Community Clinic Pilot Sites WIC Data Interfaces Promotion, Awareness and Adoption EMR Data Interfaces Three clinic sites with data in/reports out Interface development In progress SDIR-EMRs; goal to add height/weight to immunization data feeds Funding opportunities Data field comparability Data sharing rules and approvals Obesity Initiative Healthcare Domain Other initiative domains Broader rollouts within Community Clinic systems

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Focus Group Goals Determine how height and weight data entry fit into or interfered with clinic flow patterns Assess provider attitudes toward, and experience with using SDIR BMI during the pilot implementation Understand impact of SDIR BMI use on childhood obesity prevention and management practices in a primary care setting, and Ascertain primary care provider needs for, and interest in having aggregate data on their patient or clinic population.

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Technical Assistance Process Focus group with clinic administrators and providers Observation of “clinic flow” and support with Future State model and Action Plan to identify changes needed for data entry and use of BMI growth charts with families Clinic support: focus on data entry, patient level reporting and summary reporting in 3 CHC clinic sites Meeting facilitation and support in all approvals and authorizations required for height and weight sharing Support to SD COI to promote increased use of BMI feature of SDIR and awareness of potential uses of data for clinical, administrative and programmatic usage Business case development for advocacy and support for SDIR BMI

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services SDIR BMI Features Height and weight data captured by SDIR Calculation of BMI by comparison with CDC reference population Plot BMI percentile-for-age on growth chart; printable for provider & families

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Sample BMI chart

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Initial Findings Providers use BMI ‘wheel’ to calculate BMI by hand Duplicate reporting of BMI required due to CHDP/EPSDT requirement for hand-calculated BMI to appear on a hard copy form (PM 160) Data entry into SDIR BMI is not in real time so cannot use BMI charts during patient visit

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Feedback from Physicians & Clinic administrator Reporting needs: Individual patient-level reports of BMI and BMI percentile Clinic-level reports to compare obesity prevalence by provider or clinic and assess effectiveness of obesity treatment programs Families may have difficulty understanding BMI chart & concepts covered in obesity counseling; color-coding chart would help Obesity treatment and referrals: Referrals made, but few obese patients maintain enrollment in treatment programs

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Theoretical model of factors influencing Use of SDIR BMI Feature

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Overall Project Progress to date As of 2009, the SDIR BMI data now represents 1,605 children in San Diego County. Data entry has increased at some sites due to promotion of feature by Obesity Initiative Protocol established in some sites to collect and enter height/weight for all well-child health visits Two clinics now receive quarterly BMI and obesity prevalence summary reporting from the SDIR to monitor their population

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services BMI Values Entered Pre- and Post- SDIR BMI Workgroup effort

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Sample ad hoc clinic report

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Overall Results/Lessons Learned from the focus group and initial site Clinic administration & practitioner buy-in essential Must specify protocol for which clinic visits/data should be entered Clinic process mapping can improve frequency of: –Data entry –Efficiency of use of BMI functionality –Quality of physician time with patients Incorporate electronic data transfer of height/weight measurements if available Alerts for bad data should be built into system Regular data quality reviews should be performed

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Vision for Increasing SDIR BMI Data Volume Through Data Transfers

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Expected Benefits of H/W/BMI in SDIR For providers: –Plotting growth & BMI charts (minimize the burden on clinic staff required to hand calculate BMI and BMI percentiles) –Identify overweight and obese children and enhance physician ability to counsel overweight patients and families. For Clinic, Medical, and Program Directors: –SDIR can provide aggregate reports to compare BMI screening rates and obesity rates across clinics or populations or reveal disparities and differential effectiveness of treatment in subpopulations. For county officials and those planning or implementing obesity prevention programs: –SDIR-produced aggregate reports can reveal differences in overweight and obesity prevalence rates by geographic, demographic, or institutional or policy perspectives.

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Next Steps Business case development and meeting facilitation for financial support to Electronic Medical Records height/weigh data transfer to SDIR, for private and community clinics Facilitate WIC height/weight data transfer to registry through patient consent process and State WIC to SDIR communication and data extract Increase and measure awareness of clinic staff for use of SDIR BMI Disseminate key findings from pilot site clinic flow Lean study and Action Plan Assess SD COI member organization awareness and impact of SDIR BMI activities

County of San Diego ● Health and Human Services Agency ● Public Health Services ● Epidemiology & Immunization Services Acknowledgements Pilot sites: Imperial Beach Community Health Center North County Health Services La Maestra Health Center County of San Diego Health & Human Services Agency: Wilma Wooten, MD, MPHKaren Waters-Montijo, MPH Public Health OfficerImmunization Branch Chief Officer Epidemiology & Immunization Services staff