1. Public Health IT Lecture a
Unit 4: Public Health Enabled Electronic Health Records, Decision Support, and Their Role in the Meaningful Use of Health Care Technology
Welcome to Public Health IT. This will be a lecture on public health enabled electronic health records, decision support, and their role in the meaningful use of health care. This is lecture a.
Lecture a
This material (Comp13_Unit4a) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC This material was updated by Columbia University under Award Number 90WT0004.
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2. EHRs, Decision Support, and Meaningful Use of HIT Learning Objectives
Objective 1: Discuss the New York City Department of Health and Mental Hygiene partnership with a commercial EHR vendor and how it created a public health – enabled EHR
Objective 2: Describe the EHR "meaningful use" movement and how it could transform existing clinical / public health practices
The learning objectives for the public health enabled electronic health records, decision support, and their role in the meaningful use of health care unit are: number one, discuss the New York City Department of Health and Mental Hygiene partnership with a commercial EHR vendor and how it created a public health-enabled EHR; and two, describe the EHR “meaningful use” movement and how it could transform existing clinical/public health practices.

3. EHRs, Decision Support, and Meaningful Use of HIT Learning Objectives (Cont’d – 1)
Objective 3: Demonstrate knowledge of public health – oriented clinical decision support including an integrated strategy using multiple tools such as alerts, order sets, smart forms, and quality reporting
Objective 4: Describe the strategies, features, and systems needed for public health agencies to define and build the necessary connections to EHRs as identified by the “meaningful use” legislation
Objective 5: Identify the essential features of four primary public health IT functions including syndromic surveillance, bidirectional immunization registries, public health alerts, ad – hoc reporting, etc.
Other learning objectives that will be covered later in this unit include: number three, demonstrate knowledge of public health-oriented clinical decision support including an integrated strategy using multiple tools such as alerts, order sets, smart forms, and quality reporting; number four, describe the strategies, features, and systems needed for public health agencies to define and build the necessary connections to EHRs as identified by the “meaningful use” legislation; and five, identify the essential features of four primary public health IT functions including syndromic surveillance, bi-directional immunization registries, public health alerts, ad-hoc reporting, etc.
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4. New York City public health goals
Take Care New York advises that every New Yorker take these 10 steps to lead a healthier life:
Have a regular doctor or other health care provider
Be tobacco free
Keep your heart healthy
Know your HIV status
Get help for depression
Live free of dependence on alcohol and drugs
Get checked for cancer
Get the immunizations you need
Make your home safe and healthy
Have a healthy baby
For the next several slides we will be using the New York City Department of Health and Mental Hygiene as an example of meaningful use. In New York City, the Department of Health and Mental Hygiene has a number of goals, and these goals form the basis for much of their activities. They are called the Take Care New York goals and they focus New Yorkers on following these 10 steps to lead a healthier life such as being tobacco-free, getting help for depression, getting checked for cancer and getting the immunizations that you need. These are meaningful goals. They are meaningful because they help you change your life to get healthy. But it's not enough to have a goal; you have to have an organization through which to make these great goals happen.
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5. Primary Care Information Project (PCIP)
The Primary Care Information Project (PCIP) is a bureau of the NYC Department of Health and Mental Hygiene
PCIP is also the regional EHR extension center for NYC
Since 2005, PCIP has administered the nation’s largest community EHR expansion program
One of these groups within the Department of Health, is a newly created bureau, called the Primary Care Information Project (PCIP), created in Its goal is to do something meaningful. It has focused during the last five years on administering the nation's largest community Electronic Health Record (EHR) expansion program. If you know something about the Regional Extension Center concept, you're in luck. This is an organization that is helping providers implement electronic health records. Let’s now review how the PCIP has been doing.

6. Primary Care Information Project (PCIP) (Cont’d - 1)
Practices
Sites
Providers
Hospitals 4 42
798
Community Health Centers 35 98
757
Small Practices
419
443
947
Total
458
583
2502
Here is a map of the five boroughs of the New York City area. Notice, we currently have over 2500 providers that have implemented an electronic health record through our organization or are in the pipeline to do so. The EHR sites are scattered throughout all of the New York City area. The practices come in all different shapes and sizes. There are various sizes represented from single provider sites, small provider practices, and on up to multi-site community health centers that have more than 10 providers. Therefore, we have physicians all over New York City using electronic health records. We'll talk more about what to do to make their lives easier.
4.1 Table (Primary Care Information Project, 2010).
4.1 Figure (Primary Care Information Project, 2010).
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7. ECW / PCIP partnership eClinicalWorks (ECW):
A CCHIT – certified vendor providing one integrated system for practice management / EHR / billing / PHR
2007 partnership between PCIP and eClinicalWorks to develop public health functionality in response to Department of Health initiative: Take Care New York
This experience helped to shape the criteria for meaningful use as envisioned by PCIP’s founder Dr. Farzad Mostashari
Now, a little bit about the electronic health record. In 2007, the Primary Care Information Project formed a partnership with the vendor eClinicalWorks with the purpose of making a public health-enabled electronic health record and particularly, to integrate much of the goals of the Take Care New York initiative which we covered previously. The goal is to get people healthy by putting the public health mission in front of the physicians at the point-of-care. This was the innovative vision of Dr. Farzad Mostashari the founder of PCIP, of which many elements can be seen in new federal policies surrounding the EHR meaningful use discussions.
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8. Deal for the providers We give them… They are responsible for…
ECW software
10 days of onsite training
Data migration services
Business analyst services
Discounted ASP services
Onsite technical assistance
They are responsible for…
Hardware
Staff time spent in training
Lost revenue
Self – tutorial and web – based learning
$4,000 per FTE for technical assistance
What is the deal being offered to the providers? We give them a discounted rate on the eClinicalWorks software, 10 days of on-site training on how to use it, and help them throughout the implementation process. However to get this great deal with all of these services, they have to contribute some of their own resources and money. The providers are responsible for purchasing the hardware, servers, network, computers, and so on upon which the eClinicalWorks software will run. They're responsible to spend time and to include their staff in the training to use the electronic health record in order to train themselves on how an EHR should be used. Additionally, they contribute 4,000 dollars per full time employee (FTE) into a technical assistance fund that helps cover some of the costs for our services that we provide them through the Primary Care Information Project.
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9. Additional services Contemplation Implementation
Provider outreach and education
Vendor selection
Group purchasing discounts
Readiness assessments
IT consultation
Partners for financing and workforce development
Implementation
Contract accountability
Project management
Workflow redesign (large practices)
Social networking
Communication outreach
What are these additional support services that the providers receive for their $4,000 dollars? There are many different services and individuals involved in delivering a wide variety of help to the providers and we’ll cover some of them here and leave the rest for you to review in the slides. First, when a provider approaches us or we approach them, they are in the contemplation phase. They’re not sure they want to join. So what do we do? We give to them outreach materials that explain the program and what services they might benefit from. We explain how we’ve vetted the EHR systems that we selected, and additionally ones in the future as part of the regional extension center option. We explain the benefits of having already done this process for them. It is kind of like when you go out to buy a brand new TV, you don’t know what brand you want. But let’s say you have a trusted friend that has already reviewed a bunch of TVs for you and he points them out and says here are three good TVs for you, why don’t you try one of these? That is helpful and benefits you and cuts down on the lack of inertia to get started with adopting an electronic health record system. In addition there’s a group purchasing discount. We also provide IT consultation as they try to identify the cost to their practice to get set up with the system. Once they’ve decided to go with us then we move on to the implementation phase where we help manage the contract with them and provide some project leaders: people that help them throughout each step of the process when they are negotiating with the vendors to set up. During the installation we help with the setup of additional features such as lab interfaces, e-prescribing, client portals and other essential features. Some of larger practices need more help in the form of workflow redesign so they know how to practice in this new electronic environment. Finally, we provide them with a virtual support network as we create relationships at conferences and training classes across our group of clinics so that they are able to chat with colleagues and enable them to leverage shared best practices.
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10. Additional services (Cont’d – 1)
Post go live
Revenue cycle optimization
EMR consulting
QI consulting
PCMH preparation
Privacy and security consulting
Workflow redesign (small practices)
Patient portal training
Interfaces (e.g., labs, registries
Pilots
Meaningful use
Quality measures utilization measures
Health Information Exchange
Interoperability
Patient engagement
Biosurveillance
When they’ve signed up with us, they implement the system and go live. Once the system is running, we do not drop them and leave; instead we continue to provide them with additional support and more services. One service that we provide is consultation in the form of EMR Super-User consulting. For example if a physician is having a problem with a particular system feature such as clinical decision support or the registry, they may not know how to query for a panel of patients with particular conditions. One of our Super-Users can come to their practice and demonstrate these features in detail. Additionally, we might help them in Quality Improvement Initiatives such as helping them improve the quality of care delivered for their diabetics. We can help them secure their practice and their EHR from potential security breaches. Lastly, one of the greatest benefits has actually been the setting up of lab interfaces in these small practices which typically would not be on the priority list for the lab companies as their volume of labs is too small. This is an essential feature for an EHR system to function well. So, these are all really amazing services. In addition, we can help them understand more about their practice by tracking quality metrics from their system, help them run report cards and define measures of information that allow them to know how they are doing tracking their patient population. The providers can know of all their adult diabetics with particular conditions, how many of them came in for a visit in the last year or have had the appropriate lab follow-up work. That's the type of information we provide in quality measure report cards back to the providers comparing them across the community of clinics that are in our program. These are just some of the many valuable services that we give to our providers.
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11. 2010 goals
Extend EHRs that support prevention to 2,500 Medicaid providers, over 1.5 million patients
Support EHR – enabled providers in a standardized health information exchange
Design and implement a pay – for – performance incentive program that supports and recognizes preventive measures
Prepare providers to meet “Meaningful Use” requirements
The ultimate goal is by 2010 for PCIP to extend EHRs to 2,500 Medicaid providers serving an underprivileged group of patients of over 1.5 million. We would like to see them linked into health information exchanges. Our efforts are to work with our local HIE organizations which look to link primary care practices to hospitals, other outpatient facilities and so on, to provide an electronic exchange of documents to create a continuum of care by which people can get healthy and meet the Take Care New York goals. There are additional programs that are available to compensate physicians and we ask them to spend additional time with patients in order to promote preventative care. It’s important that physicians provide preventative care such as diabetes and smoking cessation counseling to patients and help them understand their risk. The last goal of our group is to meet meaningful use and reach the necessary thresholds for the EHR incentive payments.

12. NYC REACH Extension Center
The Extension Center must be capable of providing assistance to all providers in a designated region, but priority shall be given to providers that are primary care physicians and / or other health care professionals with prescriptive privileges, such as physician assistants and nurse practitioners
Another evolving mission of PCIP has been to fill the role of the New York City Regional Extension Center.
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13. NYC REACH Extension Center (Cont’d – 1)
A few of the primary priorities of NYC REACH are:
Assisting providers to adopt an EHR
Providing assistance to reach “Meaningful Use” of the EHR
Enabling the electronic exchange of health information between EHRs
Reporting of quality measures using the EHR
The extension center must be capable of providing to people in our region the type of support that gets them to reach at least the priority areas such as: assisting providers to adopt an EHR, which we have just discussed in depth the process, tools, and services that are necessary to help a practice reach that goal. Second, instead of just quality metrics, we now have a whole new set of metrics centered on "meaningful use" of the EHR. Examples would be are they e-prescribing? Are they transmitting public health relevant information to our immunization registries or syndromic information? Third, we are continuing our mission to create a continuum of care by linking EHRs across electronic health information exchanges. And fourth, we will report all of these quality metrics back to organizations like an extension center and related partners to assist these providers to use technology to meet meaningful clinical goals with the hope this would lead to meaningful clinical outcomes.
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14. Meaningful use as a “launch pad”
The American Recovery and Reinvestment Act (ARRA) provides over $40 billion in health IT incentives to assist and reward providers for achieving “meaningful use”
Primary goal of HIT stimulus
Use timely and easily accessible information to improve the delivery and consistency of effective health care
Adoption of technology is not enough
Five key areas to integrate technology to improve overall health and delivery systems
Thus meaningful use is a launch pad. We want to get the right information to the right people in the right place to improve and deliver consistent and effective health care. That's the goal. That's why we're spending 40 billion dollars in health care incentives. It's not enough to just have the computer in your office, just to adopt it, to say I got it, been there, done that, got the T-shirt. We need to integrate the technology to improve health and that's what is to be accomplished.
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15. Meaningful Use goals
Goal 1: Improve quality, safety, efficiency, and reduce health disparities
Provide access to comprehensive patient health data for patient’s health care team
Use evidence – based order sets and CPOE e – prescribing
Apply clinical decision support at the point of care
Generate lists of patients who need care and use them to reach out to patients
Report to patient registries for quality improvement, public reporting, etc.
This will be accomplished by focusing on a number of goal areas. First, we need to improve the quality, safety, efficiency of health care and reduce health disparities. We need to provide comprehensive access to information. We need to provide evidence-based order sets to the patient's care team. We can have providers prescribe the right medications and add additional clinical decision support to prompt them to focus on the right outcomes on the right issues when the patient is there in front of them and to generate list of patients for follow-up and so on.
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16. Meaningful Use goals (Cont’d – 1)
Goal 2: Engage patients and families
Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health
Goal 3: Improve care coordination
Exchange meaningful clinical information among professional health care team
The second goal of meaningful use would be to engage patients and family members. We need to get information out to the patients. How many times have you as a patient wanted access to your own health record and it was not easy to ask for or available? That is a challenge. And third, we need to be able to improve care coordination. We need to be able to share information not just with the primary care provider in his own office; he needs to be able to relay that to specialists who are doing the follow-up care.
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17. Meaningful Use goals (Cont’d – 2)
Goal 4: Improve population and public health
Submit data (immunization, syndromic surveillance and reportable disease) to public health agencies
Goal 5: Ensure adequate privacy and security protection for personal health information
Ensure privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law
Provide transparency of data sharing to patients
Fourth and being a little biased, I would say most importantly for us as public health IT practitioners, is to improve the public health, of everyone in the city. This is about the people out there in the community and not just the patient in front of one physician. It's about getting a whole neighborhood more healthy and happy. So how can we do this? We need to be able to track and report disease. We need to be able to vaccinate and get information on childhood immunizations. We need to be able to track emerging new diseases such as a new strain of influenza and be able to report this to the right people in the public health agencies for follow-up. And finally, to meaningfully use these systems, we need to, of course, protect the privacy and security of personal health information. We need to ensure that the proper safeguards are put into the systems and that the patients know how their information is being used.
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18. Improve population and public health: 2011
Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice
Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice
So far we have been talking about the broad goals of an extension center and the Primary Care Information Project. Now we are going to start talking more specifically about what particular features are on the table for meaningful use for improving population and public health. By 2011, they have asked that EHR systems be capable of submitting electronic syndromic surveillance data to public health agencies in accordance with applicable law. And second, be able to send electronic immunization registry information to the public health agency.
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19. Improve population and public health: 2013
Receive health alerts from public health agencies
Provide sufficiently anonymized electronic syndrome surveillance data to public health agencies with capacity to link to personal identifiers
Receive immunization histories and recommendations from immunization registries
By 2013, the goal would be to enable an electronic health record system in some fashion to receive public health alerts to be able to display to the provider at the point of care. As we continue to go down the list, to provide sufficiently anonymized electronic syndrome surveillance data to public health agencies. Not just counts of how many people have fever but now are able to have a list of identifiers for patients that could be used for follow-ups in the case of an outbreak whether that's flu or some other potential emerging disease. The last goal for 2013 is to receive immunization history back from the public health department and be able to reconcile and integrate it back into the system.
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20. Improve population and public health: 2015
Dynamic and ad hoc quality reports
Clinical dashboards
Use of epidemiologic data
Automated real – time surveillance
Adverse events
Near misses
Disease outbreaks
Bioterrorism
By 2015, we would have the ability for a public health agency to use electronic health records to do dynamic ad hoc quality reports and to be able to produce clinical dashboards of what really is the state of health in our community. These are pretty ambitious goals but we want to make a difference in population and public health.
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21. Unit 4: EHRs, Decision Support, and Meaningful Use of HIT, Summary – Lecture a
Significant support was given to providers in New York City by the Health Department to adopt a prevention – oriented EHR capable of sending electronic health data, particularly syndromic surveillance, quality measurement, and immunization histories
Significant support was given to providers in New York City by the Health Department to adopt a prevention-oriented EHR capable of sending electronic health data, particularly syndromic surveillance, quality measurement, and immunization histories.

22. EHRs, Decision Support, and Meaningful Use of HIT References – Lecture a
Dr. Farzad Mostashari is currently serving as Deputy National Coordinator for Programs and Policy
Mostashari F, Tripathi M, Kendall M. A tale of two large community electronic health record extension projects. Health Aff (Millwood) Mar-Apr;28(2):
Primary Care Information Project. Accessed: October 1, 2010 from
Singh MP. Project Management: Lessons from the Primary Care Information Project. In Medical Informatics. An Executive Primer. Editor Ong K Healthcare Information and Management Systems Society (HIMSS), Chicago Ill. Second Edition Chapter
Charts, Tables, Figures:
4.1 Table: DeLeon S, Shih SC. Tracking the delivery of prevention-oriented care among primary care providers who have adopted electronic health records. J Am Med Inform Assoc. (2011), ahead of print. August 19, 2011.
4.1 Figure: Primary Care Information Project. Accessed: October 1, 2010 from
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23. Unit 4: EHRs, Decision Support, and Meaningful Use of HIT, Lecture a
This material (Comp 13 Unit 4a) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated in 2016 by Columbia University under Award Number 90WT0005.
No audio.
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