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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 11201 NIDA RFA-DA-06-001 (R01): Enhancing Practice Improvement in Community-Based Care for Prevention and Treatment of Drug Abuse
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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
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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
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PURPOSE Evaluate the implementation of an electronic information system using the following domains: – –Satisfaction – –Productivity – –Finance – –Risks – –Quality
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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
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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
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STUDY DESIGN Prospective, comparative study Pre-post implementation evaluation 3-year timeline
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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
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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
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PRE-POST DATA ANALYSIS Satisfaction Chi-square test Productivity t-test Finance t-test Risks Cochran-Armitage Quality Chi-square exact test
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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
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SATISFACTION: PATIENT SURVEYS # of Surveys Administered: 1,000 - Apportioned by Clinic Census - Process: First come/first served with 2-ride MetroCard - 6 Questions
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Patient Pre-implementation Survey: How long have you been with ARTC? %
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Q6: How satisfied are you with the overall quality of care you receive? % Mean: 3.86 Std. Deviation: 0.99 Range: 1-5
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SATISFACTION: STAFF SURVEYS Eligible employees: Clinicians and Managers # of eligible employees: 148 # of surveys returned: 99 (66.9%) 17 Questions
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Q6: How satisfied are you with the system overall? % Mean: 3.14 Std. Deviation: 0.90 Range: 1-5
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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
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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
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FINANCIAL PERFORMANCE Evaluation Period: 2006 and 2007 Measures 2006 2007 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
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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
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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
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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
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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
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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)
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Hepatitis C Antibody Testing Results (N=670)
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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
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QUALITY: HEPATITIS C VIRAL LOAD 151 (numerator) tested 164 referred or refused 178 (denominator) = 342 - 164 151/178 = 85% done
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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
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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
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QUALITY: STUDY POPULATION PRE POST Due Date: 11/1/07 – 4/30/08 11/1/09 – 4/30/010 N 194 143 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%
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QUALITY: RESULTS * + 30 days of 1-year anniversary ** < 365 days after admission
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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
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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
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ACKNOWLEDGEMENTS PATIENTS AND STAFF OF THE ADDICTION RESEARCH AND TREATMENT CORPORATION, A COMMUNITY- BASED SUBSTANCE ABUSE SERVICE AGENCY
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