The Primary Care Information Project Sarah Shih, MPH Exec. Dir. Healthcare Quality Information New York City Department of Health and Mental Hygiene

NYC’s Health Agenda Take Care New York 1.Have a Regular Doctor or Other Health Care Provider 2.Be Tobacco-Free 3.Keep Your Heart Healthy 4.Know Your HIV Status 5.Get Help for Depression 6.Live Free of Dependence on Alcohol and Drugs 7.Get Checked for Cancer 8.Get the Immunizations You Need 9.Make Your Home Safe and Healthy 10.Have a Healthy Baby

Health Care that Maximizes Health HEALTH INFORMATION SYSTEMS that are oriented toward prevention PAYMENT that rewards disease prevention and the effective management of chronic disease REDESIGNED PRACTICE WORKFLOWS PATIENT ENGAGEMENT that highlights prevention

Focused on Medically Underserved Patients in NYC We have secured signed commitments from 2,100 providers in 379 practices and at 480 sites ~ 1 new provider goes live on the EHR every day PracticesLiveIn Progress Practice: IS ratio Small Practices :1 Health Centers1813*15:1 Hospital OPDs32*4:1 Sub-total *Practice with sites both live and in implementation

5 BRINGING THE RESOURCES OF LARGE NETWORKS TO INDEPENDENT SMALL PRACTICES - A “VIRTUAL NETWORK” Kaiser Permanente NYC PCIP

PCIP, eCW & Practice team structure PCIPeCWPractices SmallLarge Implementation specialists Project Managers, Business Analysts, SAMs Providers, Office Managers Project Management Team Infrastructure teamTechnical SpecialistsIT ConsultantIT Department Interface Coordinator (PM, labs and CIR) Lab Interface teamProviders, Office Managers IT Department, Ref/In-house lab Quality AssuranceDevelopment teamProviders, Office Managers Site Administrators Quality Improvement consultants, Super Users, Billing consultants Trainers, Billing Specialist, Business Analyst Providers, Office Managers, Biller Quality Improvement Unit, Financial Dept. Privacy and Security consultants Development teamProviders, Office Managers IT Department, Legal Development team Providers, Office Managers Super Users

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 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 MEASURE REPORTS Side-by-side provider comparisons of performance on quality measures 8 Key Features of the TCNY Build

Small Practice Consulting Approach

9 Following Medical Home and Chronic Care Models Useful framework for organizing QI work ▪ Actionable curriculum consisting of a collection of discrete activities and achievable goals ▪ Focus on “whole-practice” redesign (e.g. teamlet care – C. Sinsky) ▪ Provide actionable and meaningful feedback ▪ View EHR-derived quality measure data on a routine basis ▪ Provides incremental recognition “BOOTS ON THE GROUND” ▪ Assist practices through the process and lower the “activation energy” ▪ Software, QI, EMR consulting, Pay for Performance, relationships ▪ Partnership with NCQA- multi-site survey ▪ Keep practices focused on care & and reduce administrative burdens ▪ Average physician spends $68,274 per year interacting with insurance plans* ▪ Focus practices on areas to have the highest impact for health ▪ Provide share resources to practices (care coordinators, nurses, panel managers) ▪ Conduct patient outreach using the data from HER *J. A. Sakowski, J. G. Kahn, R. G. Kronick et al., "Peering into the Black Box: Billing and Insurance Activities in a Medical Group," Health Affairs Web Exclusive, May 14, 2009, w544–w554

How do we know whether providers are meaningfully using the EHR? PCIP staff –Scheduled on-site visits –Demo of registry query functions Data Transmissions from EHR –Encounter information from PM –Utilization of EHR metrics –Quality Measures (EoC)

Average Encounters Per Month by Practice Size* *Limited to small practices that have been on the EHR for 6 months or more. Data available on ~116 small practices

PCIP Contractual Expectations with Providers Selected Measures for Demonstrating Use of EHR 1.Visits where office visit CPT codes were entered into the progress note. 2.Visits where an order set was used as part of the progress note. 3.Visits where a smart form was used as part of the progress note. 4.Visits where blood pressure was entered into the progress note. 5.Visits where allergy data was entered in a structured format 6.Insurance claims created over total number of insurances for patients that month 7.Visits where medications were prescribed through the EHR 8.Prescriptions entered into the EHR that were sent via fax or electronic interface 9.Labs reviewed over labs ordered 10.Current medications were entered or verified in the EHR 11.Months in a 6 month period when required data files were transmitted to the DOHMH 12.Months in a 6 month period when all core utilization measures were reported to the DOHMH

Proposed Meaningful Use Measures Overlapping with Data Transmitted to PCIP Line2011 Measures (Draft from HITECH)Level 9, 10% of permissible RX's transmitted electronicallyProvider 21,22 % lab results incorporated into EHR in coded format [OP,IP] Practice Provider 26 % of encounters for which clinical summaries were provided [OP, IP]Provider 28 % of encounters where med reconciliation was performed [OP, IP]Practice 30 Report up-to-date status for childhood immunizations [OP]Practice 31 % reportable lab results submitted electronically [IP]Practice

EHR Utilization Transmitted to PCIP Snapshot of monthly activities Number of practices with EHR use data –133 practices in July and August 2009 –85 have been using EHR for 8 months or longer *limited to practices on the EHR for 8 months or longer EHR use transmissionsTotal Jul*Total Aug* Lab results transmitted48,07252,183 Lab results reviewed56,73163,882 Use of Medicaid State Rx Claims2,4222,560 Active patients508,079516,283

Proposed Meaningful Use Measures Currently within PCIP Quality Measures Line2011 Measures (Draft from HITECH) 1% diabetics with A1c under control [OP] 2% of hypertensive patients with BP under control [OP] 3% of patients with LDL under control [OP] 4% of smokers offered smoking cessation counseling [OP, IP] 5,6% of patients with recorded BMI [OP] 14% of patients over 50 with annual colorectal cancer screenings [OP] 15% of females over 50 receiving annual mammogram [OP] 16% of patients at high-risk for cardiac events on aspirin prophylaxis [OP] 17% of patients with current pneumovax [OP] 19% eligible patients who received flu vaccine [OP] Note: Quality Measures are collected at the provider level and stratified by insurance type. For some practices, stratified by race/ethnicity, though few providers are completing the field for race/ethnicity

Preliminary Data – Quality Measures Mar08 to Feb09Aug08 to Jul09 Measure NameNMean (std)Sum*NMean (std)Sum* A1C control (< 7%) (16.6) (17.0)2,498 Antithrombic Treatment (21.2)8, (21.3)13,686 Asthma control (5-11 yrs)387.8 (18.4) (12.4)104 Asthma control (12-17 yrs)274.1 (16.4) (8.4)54 Asthma control (18-56 yrs)245.7 (36.4) (27.5)105 Body Mass Index (29.8)83, (26.9)126,842 BP Control ≤130/80 DM (13.5)4, (17.3)7,358 BP control ≤140/90 HTN (16.4)12, (16.0)18,480 BP Control ≤140/90 IVD (16.3) (20.1)868 Cholesterol Control <100 gen pop (22.5) (21.3)3,145 Cholesterol Control <100 IVD,DM (18.5) (15.7)1,879 Breast cancer screening164.5 (5.8)6, (7.9)22,034 Colorectal cancer screening81.9 (1.3)4, (6.2)22,008 Influenza vaccine (over 50) (18.4)25, (15.2)38,431 Pneumococcal vaccine669.8 (13.0)27, (13.5)45,641 Smoking cessation intervention (14.5)4, (23.6)8,253 *A population estimate was derived by summing across practice denominators per measure

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