Transcript phdsc.org

HIT:
Replacing the Missing Link
Between Community Health Care
and Public Health
Neil S. Calman, MD
The Institute for Urban Family Health
New York City
About the
Institute for Urban Family Health
• Institute for Urban Family Health
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11 Community Health Centers –
7 in Bronx, 3 in Manhattan, 6 in Mid-Hudson Valley
8 homeless healthcare sites in Manhattan
2 School based health centers
2 Family Practice Residency Training programs
250,000 primary care visits / 105,000 patients
• Fully paperless since September 2002
• Epic (Verona, Wisconsin) EHR / PMS
1
It is Impossible
to Deliver
State-of-the-art
Health Care
without an EHR
2
Community Health
Centers are a Vital
Part of our Nation’s
Public Health
System
The Benefit of Early Detection of Syndromes
Number of Cases
Symptom Onset
Severe Illness
t
Release
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Days
Single patient visit
yields complex EHR data
• Patient Address
• Race / Age / Gender
• Medical history
• Temperature
• Height/weight
• Respirations
• Provider Location
• Reason for visit
• Problem list
•
•
•
•
Procedures
Medications
Lab results
Diagnoses
Flu isolates
0.060
0.45
0.050
0.40
0.35
Blue
= ER “flu/fever”
Red
= Flu “A” isolates
0.040
0.30
Violet = Flu “B” isolates
0.25
0.030
0.20
0.020
0.15
0.10
0.010
0.05
0.00
7/8/03
0.000
8/8/03
9/8/03
10/8/03
11/8/03
12/8/03
1/8/04
2/8/04
3/8/04
4/8/04
5/8/04
6/8/04
Percentage of combination syndrome
Percentage of fever/flu chief complaints
0.50
EHR Fever
0.060
Blue
0.45
= ER “flu/fever”
0.40
Purple = EHR Fever >100 F
0.35
Red
0.30
= Flu “A” isolates
0.050
0.040
Violet = Flu “B” isolates
0.25
0.030
0.20
0.020
0.15
0.10
0.010
0.05
0.00
7/8/03
0.000
8/8/03
9/8/03
10/8/03
11/8/03
12/8/03
1/8/04
2/8/04
3/8/04
4/8/04
5/8/04
6/8/04
Percentage of measured temperatures
Percentage of fever/flu chief complaints
0.50
Fever AND respiratory syndrome
0.025
0.45
0.40
Blue
0.35
Brown = EHR T≥ 100o and
Respiratory Syndrome
0.30
0.020
= ER “flu/fever”
0.015
0.25
0.20
0.010
0.15
0.10
0.005
0.05
0.00
7/8/03
0.000
8/8/03
9/8/03
10/8/03
11/8/03
12/8/03
1/8/04
2/8/04
3/8/04
4/8/04
5/8/04
6/8/04
Percentage of combination syndrome
Percentage of FevFlu chief complaints
0.50
Patients of
the Institute
for Urban
Family
Health
Institute patient fevers peaked
13 days before ER visits for
Fever and Flu – this indicates
that health center data may be
the first “signal” of an
impending epidemic.
Institute fever data responded to
Flu B outbreak-ED data did not
3
Community Health Centers
can expand knowledge
about the community’s
health and use that
information to improve its
care of patients
0.50
0.06
Step 1: EHR institution to public health agency – clinical encounters
0.45
0.05
0.40
0.35
0.04
0.30
0.25
0.03
0.20
0.02
0.15
1
0.10
0.01
0.05
0.00
7/8/03
0.00
8/8/03
9/8/03
10/8/03
11/8/03
NYCDOH
IUFH
2
12/8/03
1/8/04
2/8/04
3/8/04
4/8/04
5/8/04
6/8/04
DOH receives
signal of
outbreak of
respiratory
illness
Step 2: Public health agency to EHR institution
- epidemiologic awareness
6 0. 0
0 5. 0
5 4. 0
5 0. 0
0 4. 0
5 3. 0
4 0. 0
0 3. 0
3 0. 0
5 2. 0
0 2. 0
2 0. 0
5 1. 0
0 1. 0
Cough!
Cough
1 0. 0
5 0. 0
0 0. 0
0 0. 0
4 0/ 8/ 6
Provider
4 0/ 8/ 5
4 0/ 8/ 4
4 0/ 8/ 3
4 0/ 8/ 2
4 0/ 8/ 1
3 0/ 8/ 2 1
3 0/ 8/ 1 1
3 0/ 8/ 0 1
3 0/ 8/ 9
3 0/ 8/ 8
3 0/ 8/ 7
Patient
Practice Alert in EHR for
age < 18 yo, cough/fever
requests provider to do
full cultures and call
DOH for immediate pickup and ID by DOH lab =>
message in EHR
supports Dx of future pts
4
Few Measurable Quality
Improvements Come
from EHRs –
Almost All are Facilitated
by EHRs
and Cost Real $$$$$
Clinical Decision Support – Impact on Vaccines
HgbA1c Progress
7.8
7.75
7.7
7.65
7.6
7.55
M
ar
-0
5
05
Ja
n-
ov
-0
4
N
Ju
l-0
4
Se
p04
M
ay
-0
4
M
ar
-0
4
04
7.5
Ja
n-
HGBA1C SCORE
Average A1c for Past 12 Months
10 Take New York Indicators
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
FORMER SMOKER BPA PATHWAY
BPA satisfied
Identify last
recorded quit
date and date
of last status
update
Clinical Decision
Support –
Tobacco Best
Practice Alert
No BPA activated
Store status
update
verification
date.
NO
NO. BPA not
satisfied.
Was last quit date
within past 2 years
(or null)?
YES
Was last status update
< 90 days ago?
Congratulation, you've been
tobacco-free for ___ days!
Offer relapse prevention literature.
Review current treatment plan
NO
Was last update >
12 months ago?
YES
BPA #4b:
"Update
Smoking
Status"
BPA #4a:
"Update
Smoking
Status"
Clinician clicks status radio
button and clicks verify
button
Clinician clicks status radio
button and clicks verify
button
Was current
status updated
and verified?
NO
Relapse prevention
counseling in past 90 days
OR quit date > 12 months
ago?
STOP
Was current
status updated
and verified?
NO
YES
BPA #5: "Review
relapse prevention
interventions"
NO
YES
YES
BPA #4a satisfied
NO
BPA #4a not
satisfied.
Patients Seen at Least Once by Their
Primary Care Provider
Men >35; Women>45 Who have
had their cholesterol tested
Men >35; Women>45 Who have
had their cholesterol tested
Depression Screen with PHQ2
Depression Screen with PHQ2
Recorded Substance Abuse Hx
Recorded Substance Abuse Hx
Pneumococcal Vaccine >65yrs old
Pneumococcal Vaccine >65yrs old
Provider Nutritionist Referral
Rate vs. Pts Average HgBA1c
9
Most Recent HgbA1C
8.5
22
1
8
0.9
7.5
7
9
12
6.5
0.0%
10.0%
20.0%
30.0%
40.0%
Rate of Nutrition Referral
50.0%
60.0%
70.0%
5
New opportunities
emerge to get
information about
racial disparities in
health outcomes
Last Hemoglobin A1c by Race
8
7.8
Latino
7.86
n=1555
7.6
7.4
7.2
7
6.8
White
7.03
n=423
Black
7.44
n=2122
6.6
HgbA1c
Asian
7.12
n=76
90
80
70
60
50
40
30
20
10
0
White
Black
Latino
Asian
Insulin/Sens
Agent %
1 HgbA1c %
2 HgbA1c %
LDL test %
5
Power to the People
What will the future
bring …?
Its just the beginning
…..