Implementation of an Electronic Information System to Enhance Practice at an Opioid Treatment Program Steven Kritz, MD; Melissa Chu, MS; Roberto Zavala, MD; Lawrence S. Brown, Jr., MD, MPH, FASAM Division of Medical Services, Research and Information Technology, Addiction Research and Treatment Corp, Brooklyn, NY NIDA RFA-DA (R01): Enhancing Practice Improvement in Community-Based Care for Prevention and Treatment of Drug Abuse

DISCLOSURES There are no financial interests or other disclosures to report for any of the authors involved in this project Grant support provided by NIDA: R01 DA022030

BACKGROUND   Electronic information systems rarely utilized or evaluated in substance abuse treatment settings   ARTC serves a racially, ethnically and economically disenfranchised population   ARTC serves a population that experiences significant disparities in access and quality of healthcare

PURPOSE Evaluate the implementation of an electronic information system using the following domains: – –Satisfaction – –Productivity – –Finance – –Risks – –Quality

AIMS & HYPOTHESES Specific AIM 1: Satisfaction Hypothesis Overall satisfaction will increase for:  Patients  Clinicians  Managers Specific AIM 2: Productivity Hypothesis Visits will increase for:  Counseling  Primary Care  HIV Case Management Specific AIM 3: Financial Performance Hypotheses:   Revenue per capita staff will increase   Cost per visit will decrease

AIMS & HYPOTHESES Specific AIM 5: Quality Hypothesis Improved capture or timeliness of:   HCV Viral Load   Medical Assessments   Multidiscipline Assessments Specific AIM 4: Risks Hypothesis Rates will decrease for:  Patient Complaints  Patient Incidents  Medication Errors

STUDY DESIGN   Prospective, comparative study   Pre-post implementation evaluation   3-year timeline

AimMeasureData Source (Pre) Data Source (Post) Patient SatisfactionSurvey Satisfaction Productivity Clinician/Manager Satisfaction Survey # Counseling visitsClinician logs # Primary care visitsClinician logs # HIV case management visits Clinician logs Financial Revenue per capitaFinance/ HR Depts Performance Cost per visitFinance Dept AIMS, MEASURES & DATA SOURCES

AimMeasureData Source (Pre) Data Source (Post) Risks # of Complaint / Incidents / Medication Error Reports Reports to CQI Manager Quality % HCV Viral Load obtained Paper chartElectronic record % Medical assessments performed on-time Paper chartElectronic record % Multidiscipline assessments performed on-time Paper chartElectronic record AIMS, MEASURES & DATA SOURCES

PRE-POST DATA ANALYSIS   Satisfaction Chi-square test   Productivity t-test   Finance t-test   Risks Cochran-Armitage   Quality Chi-square exact test

SATISFACTION: PATIENT & STAFF SURVEYS Hypotheses:   Implementation of the electronic health record will result in increased patient satisfaction   Implementation of the electronic health record will result in increased staff satisfaction

SATISFACTION: PATIENT SURVEYS # of Surveys Administered: 1,000 - Apportioned by Clinic Census - Process: First come/first served with 2-ride MetroCard - 6 Questions

Patient Pre-implementation Survey: How long have you been with ARTC? %

Q6: How satisfied are you with the overall quality of care you receive? % Mean: 3.86 Std. Deviation: 0.99 Range: 1-5

SATISFACTION: STAFF SURVEYS Eligible employees: Clinicians and Managers # of eligible employees: 148 # of surveys returned: 99 (66.9%) 17 Questions

Q6: How satisfied are you with the system overall? % Mean: 3.14 Std. Deviation: 0.90 Range: 1-5

PRODUCTIVITY Hypothesis: Implementation of the electronic health record will result increased visits per clinician for addiction counseling, primary medical care, and HIV-related case management Eligible staff: Human Services Counselors Medical Staff Case Managers Evaluation Period: 7/1/06 to 6/30/07

PRODUCTIVITY   Human Services Staff Number of addiction related counseling services: 64,345 Data source: OASAS PAS-48 Reports   Medical Services Staff Number of primary medical care services: 5,221 Data source: ICD9 Forms   Case Managers Number of HIV counseling services: 2,680 Data source: Appointment Tracking Logs

FINANCIAL PERFORMANCE Evaluation Period: 2006 and 2007 Measures Revenue per capita staff: $75,814 $66,900 Cost per patient visit: $31.45 $31.34 Hypotheses: Implementation of the electronic health record will result in:  Increased revenue per capita staff  Decreased cost per patient visit

RISK: MEDICATION ERRORS, PATIENT COMPLAINTS & PATIENT INCIDENTS Hypothesis: Implementation of the electronic information system will result in a lower number of Medication Errors, Patient Complaints & Patient Incidents

RISK: MEDICATION ERRORS, PATIENT COMPLAINTS & PATIENT INCIDENTS   Pre-implementation Period: 7/1/06 to 6/30/07   # of Medication Errors: 8   # of Patient Complaints: 15   # of Patient Incidents: 64

RISK: MEDICATION ERRORS, PATIENT COMPLAINTS & PATIENT INCIDENTS   This domain will not be included in the post-implementation data collection: - N relatively small - Processes did not change post-implementation

QUALITY: HEPATITIS C VIRAL LOAD Hypothesis: Implementation of the electronic health record will result in a higher percent of Hepatitis C antibody positive patients tested for hepatitis C viral load Eligibility:   Admission date: 7/1/06 to 6/30/07   Length of stay: >60 days   # of Eligible Patients: 772; Data Source: Charts

Hepatitis C Antibody Testing Performed During the Study Evaluation Period (Yes N=670; No=102) Reason testing not performed: 1. Testing done on a prior admission (N=95) 2. No orders; not done (N=4) 3. Ordered; no results (N=3)

Hepatitis C Antibody Testing Results (N=670)

QUALITY: HEPATITIS C VIRAL LOAD Findings:   342 needed Hepatitis C viral load testing   151 tested   160 appropriately referred to primary MD   4 refused   27 not done

QUALITY: HEPATITIS C VIRAL LOAD   151 (numerator) tested   164 referred or refused   178 (denominator) =   151/178 = 85% done

QUALITY: ANNUAL MEDICAL & MULTIDISCIPLINE ASSESSMENTS Hypotheses:   Implementation of the electronic information system will result in a higher percent of patients having annual medical assessments within 30 days of admission anniversary   Implementation of the electronic information system will result in a higher percent of patients having annual multidiscipline assessments on or before the due date

MeasureData SourceTarget Annual Medical Assessments Pre: Paper Chart Post: Electronic Record Completion + 30 days of 1-year anniversary Annual Multi-discipline Assessments Pre: Paper Chart Post: Electronic Record Completion < 365 days after admission QUALITY: MEASURES, DATA SOURCES & TARGETS

QUALITY: STUDY POPULATION PRE POST Due Date: 11/1/07 – 4/30/08 11/1/09 – 4/30/010   N   Mean Age: 45.3yrs 45.4yrs   Percent Female: 30.9% 29.4%   Race/Ethnicity:   % Hispanic 53.1% 46.9%   % African American 36.1% 39.9%

QUALITY: RESULTS * + 30 days of 1-year anniversary ** < 365 days after admission

PRELIMINARY CONCLUSIONS   The prevalence of risk management events was too low to detect a difference   Highly statistically significant improvement in timely completion of Annual Medical and Annual Multidiscipline assessments   Improvement likely due to the system rather than patient characteristics   Further analyses underway

STUDY TEAM Principal Investigator: Lawrence S. Brown, Jr., MD, MPH, FASAM Executive Senior Vice President Sub-investigators: Carlota John-Hull, MD, Director of Medical Services Melissa Chu, MS, Director of Evaluation and Research Steven Kritz, MD, Research Project Manager Roberto Zavala, MD, Research Assistant Ben Louie, BA, Implementation Project Manager Consultants: Crystal Fuller, PhD, Mailman School of Public Health, Columbia University John Kimberly, PhD, Wharton School of Business, University of Pennsylvania

ACKNOWLEDGEMENTS PATIENTS AND STAFF OF THE ADDICTION RESEARCH AND TREATMENT CORPORATION, A COMMUNITY- BASED SUBSTANCE ABUSE SERVICE AGENCY