Transcript Subject Matter Expert Meeting Tobacco Control

The Primary Care Information Project
How Can Government Get Value From HIT?
New York City Department of
Health and Mental Hygiene
www.nyc.gov/pcip
Presentation developed by Farzad Mostashari, MD MSc
On ABCS of prevention,
USA Gets an “F”
• People at increased risk of CVD who are taking Aspirin.
– 33%
• People with hypertension who have adequately controlled Blood
pressure
– 44%
• People with high Cholesterol who have adequately controlled
hyperlipidemia
– 29%
• Smokers who try to quit get help
– 20%
Despite spending nearly 1 out of
every 6 dollars on health care
Most Room For Improvement
Proportion of Medicare Beneficiaries Receiving
Recommended Preventive Services, by Practice Size
Pneumococcal
Vaccination
**
**
Influenza Vaccination
Solo/2-person (1-2)
Small group (3-10)
Colon Cancer
Screening
Medium/large group (11+)
**
***
Mammograms
Hemoglobin A1c
Monitoring
***
Eye Examinations for
Diabetics
*
0
10
20
30
40
50
60
70
80
90
100
Proportion of Medicare Beneficiaries Receiving Preventive Care, %
* P<.05
** P<.01
*** P<.001
Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of Preventive Services to Older Adults by Primary Care Physicians. JAMA. 2005; 294:473-481.
Few Quality Improvement Tools
Multivariate Analyses: Effects Of Practice Size On Access To
Practice-Level And Quality-Of-Care Data, Physicians’ Ability
To Generate Quality-Of-Care Data Internally, And Physicians’
Involvement In Redesign Efforts, 2003
Involved in redesign
efforts (n=1,744)
Quality-of-care data
internally generated
(n=1,705)
Solo (1)e
Small (2-9)
Midsize (10-49)
Large (50 or more)
Access to any qualityof-care data (n=1,757)
Access to any
practice-level data
(n=1,757)
0
10
20
30
40
50
60
Proportion of Physicians, %
70
80
90
100
*
* Model controls for practice size, years in practice, hours a week in direct patient care, salary status, physician type (primary care vs. specialist),
certification status in specialty, and use of EMR.
Audet AMJ, Doty MM, Shamasdin J, Schoenbaum SC. Measure, Learn, And Improve: Physicians’ Involvement In Quality Improvement. Health
Affairs. 2005; 24: 843-853.
Health IT has the potential to
improve the quality of care we
deliver…
State of Health IT on the Ground
• Most ambulatory care in the US is provided in small
office settings (1-5 providers) but only 11-15% of these
offices have a health IT system.
Delivery of ambulatory care
in the US1
Adoption of HIT in Physician
Practices, by size2
38
1-2 physicians
6-10 physicians
8
1
15
44
Percentage
> 11 physicians
27
22
15
11
32
3-5 physicians
1
2-5
6-15
16-30 > 30
Number of physicians in a practice
DesRoches CM, Campbell EG, Rao SR, Donelan K, Ferris TG, Jha A, Kaushal R, Levy DE, Rosenbaum S, Shields AE, Blumenthal D.
Electronic health records in ambulatory care--a national survey of physicians. N Engl J Med. 2008 Jul 3;359(1):50-60. Epub 2008 Jun 18.
Health Care Reform and
Health Information Technology
• Health IT is endorsed as an essential
element of health care reform, and we are
investing heavily in its success
• Various expectations
– Will reduce costs dramatically1,2, 3
– Will improve quality and safety of care4
– Will enable cost-effectiveness analyses5
• But it is equally possible that we will spend
billions of dollars without public benefit
1. 30 Minute Program: American Stories, American Solutions. Christopher Hass. 2008
2. Center for Information Technology Leadership. The Value of Healthcare Information Exchange and Interoperability. 2004
3. Girosi F. Meili R. Scoville R. Extrapolating Evidence of Health Information Technology Savings and Costs. RAND. 2005
4. Center for American Progress. The Healthcare Delivery System: A Blueprint for Reform. Chapter 1. 2008
Congressional Budget Office. Evidence on the Costs and Benefits of Health Information Technology. 2008
Challenges to Health Reform through HIT
• Providers have competing practice priorities
and limited resources
• Financial burden of adoption on provider,
benefits accrue to insurance
• Reimbursement is claims-driven
– Additional quality of care delivered with the EHR (smoking
counseling, email messages, panel management) may hurt
the practice financially.
• Existing Pay-for-Performance programs too
disperse to achieve results
• Data required for quality measures reporting
not uniformly recorded
• Standards for safe, interoperable data
transmission not yet
established
8
What Is the Role of Government?
• Ensure HIT addresses priority public
health issues
– Prevention
– Quality of care
– Coordination of care
– Reimbursement reform
– Disparities in health outcomes
HEALTH
INFORMATION
SYSTEMS
oriented toward
prevention
Health Care
that Maximizes Health
CARE
MANAGEMENT
so practice workflows
support prevention and
PATIENT EMPOWERMENT
to prevent disease
and disability
PAYMENT
that rewards disease
prevention and effective
chronic disease
management
NYC Primary Care Information
Project
• Mission
– Increase the quality of care in medically underserved areas
through health information technology (HIT)
• Goals
o Extend EHRs that support prevention to 2,500 Medicaid
PCPs, over 1.5 million patients
o Provide practices with clinical quality scorecards and
practice redesign technical assistance
o Design and implement pay-for-performance incentive
program that supports and recognizes preventive
measures
NYC Primary Care Information
Project
• Resources
–
–
–
–
–
NY City: $30 million and 60 staff
Practice contributions: >$15 million
NY State: $11 million
Federal: $5 million (AHRQ, CDC)
Private: Robin Hood Fund $4-6 million, Wellpoint
Foundation $500,000, HIP/GHI $150,000
PCIP Progress (March ‘09)
• Signed Agreements
- 4 Hospitals – 741 providers
- 30 CHCs – 627 providers
- 366 small practices- 812
providers
- 2180 providers total
• Live on EHR
– 273 practices
– 381 sites
– 1531 providers
PCIP EHR Extension Approach
• Eligibility/ Commitment
–
–
–
–
Primary Care
Underserved populations (10% Medicaid, uninsured)
Quality Measure Reporting (summarized, confidential)
Financial Commitment
• Hardware and Internet
• $4k per provider QI fund
• PCIP Package
– Licenses to eClinicalWorks “TCNY” integrated EHR
– On-site training, interfaces
– 2 years software maintenance and support ($1500/yr)
Key Features of the TCNY Build
AUTOMATIC VISUAL ALERTS
1
Highlights abnormal vitals
COMPREHENSIVE ORDER SETS
4
CDSS
2
Automatically displays TCNY measure alerts
for comprehensive preventive care
QUICK ORDERS
3
One-click ordering of recommended
preventive services
Displays best practice recommendations
(meds, referrals, procedures, labs, patient ed)
MEASURE REPORTS
5
6
Summary of provider performance
on quality measures
ENHANCED REGISTRY
Identifies patient panels by diagnoses, drugs,
labs, demographics and structured data
The following storyline illustrates the
TCNY Clinical Decision Support
System in action
Jane Doe, a 48 year-old woman has come to
her family practitioner, Dr. James Bear, for an
annual exam.
1. Automatic Visual Alerts
2. CDSS
3. Quick Orders
4. Comprehensive Order Sets
5. Measure Reports
6. Enhanced Registry
• Jane Doe has
come for her annual
exam
• During the visit, Dr.
Bear’s assistant
takes her history and
vitals
• Jane mentions that
she has had a few
weeks of excessive
thirst and fatigue
Jane’s blood pressure is elevated (150/90) and highlighted in red by the AUTOMATIC
VISUAL ALERT FUNCTION. Dr. Bear can trend her BP over time.
1. Automatic Visual Alerts
2. CDSS
3. Quick Orders
4. Comprehensive Order Sets
5. Measure Reports
6. Enhanced Registry
• Based on Jane’s
complaint of
excessive thirst, Dr.
Bear performs a
glucose fasting test
and confirms his
suspicion that Jane
has diabetes
• Dr. Bear enters a
diagnosis of
diabetes into the
EHR
Based on Jane’s new diagnosis of diabetes, the CLINICAL DECISION SUPPORT
FUNCTION identifies four preventive care services that should be performed. This
list of services is automatically populated in the CDSS panel.
1. Automatic Visual Alerts
2. CDSS
3. Quick Orders
4. Comprehensive Order Sets
5. Measure Reports
6. Enhanced Registry
Dr. Bear agrees
that these tests
are appropriate
and should be
performed
The QUICK ORDER FUNCTION allows Dr. Bear to order an HbA1C test for Jane,
as well as a flu vaccine; the alerts disappear from the panel once they are ordered.
Dr. Bear may also choose to suppress alerts, if he deems them unnecessary.
1. Automatic Visual Alerts
2. CDSS
3. Quick Orders
4. Comprehensive Order Sets
5. Measure Reports
6. Enhanced Registry
Dr. Bear also
selects the “LDL
control (high
risk)” alert, which
displays the
order set for high
LDL levels
The 1st part of the COMPREHENSIVE ORDER SET displays a selected list of
recommended medications (brand & generic) for lipid control.
1. Automatic Visual Alerts
2. CDSS
3. Quick Orders
4. Comprehensive Order Sets
5. Measure Reports
6. Enhanced Registry
Dr. Bear views
other options for
high LDL levels
to provide
comprehensive
care
The 2nd part of the COMPREHENSIVE ORDER SET displays a selection of
recommended labs, immunizations, follow-up appointments, referrals as well as
printable physician and patient education materials.
1. Automatic Visual Alerts
2. CDSS
3. Quick Orders
4. Comprehensive Order Sets
5. Measure Reports
6. Enhanced Registry
Dr. Bear wants to
find out how he is
performing in
controlling high blood
pressure for his other
diabetic patients.
Using the QUALITY MEASURE REPORTS FUNCTION, Dr. Bear sees that one-third of
his diabetic patients have achieved good BP control.
1. Automatic Visual Alerts
2. CDSS
3. Quick Orders
4. Comprehensive Order Sets
5. Measure Reports
6. Enhanced Registry
Dr. Bear wants to
improve his score on
BP control and
queries the EHR to
identify patients with
poorly controlled
hypertension
Using the ENHANCED REGISTRY FUNCTION, Dr. Bear identifies five patients with high
blood pressure who do not have scheduled appointments and reaches out to each by
generating follow-up visit letters. When these patients come in, they will receive BP
control therapy and a full range of preventive services suggested by their CDSS alerts.
Alerts
• 34 preventionfocused quality
measures
• USPSTF
• NCQA
• NQF
• TCNY
Quality Reporting
Draft Practice Results: ABCS and Comparison to NYC Average
A
B
Aspirin
100%
100%
80%
80%
75%
73%
71%
69%
60%
60%
40%
35%
42%
40%
37%
40%
PRACTICE XYZ
0%
Q1
Q2
Q3
NYC
57%
59%
50%
51%
53%
54%
PRACTICE XYZ
Q1
Q4
S
Cholesterol Control (Overall)
Q2
NYC
Q3
Q4
74%
77%
Smoking Cessation
100%
74%
85%
81%
78%
80%
70%
72%
60%
60%
40%
55%
0%
100%
80%
53%
20%
20%
C
Blood Pressure Control (Overall)
40%
42%
41%
44%
20%
20%
PRACTICE XYZ
0%
Q1
Q2
Q3
# eligible pts
469
# pts met goal
# pts missed goal
Quality Measures
324
145
Aspirin
NYC
21%
9%
PRACTICE XYZ
Q1
38
84
206
21
50
195
17
34
BP Control in HTN Patients
BP<140/90
in general
population
34%
0%
Q4
401
46%
40%
BP<130/80
in pts with
DM
BP<140/90
in pts with
IVD
197
Q2
93
174
42
23
51
Cholesterol Control
TC<240 or
LDL<160 in
general pop’n
LDL<100
in pts with
IVD or DM
Your practice has saved ### lives
Q3
80
7
73
Smoking
Cessation
NYC
Q4
Health eHearts
A pilot incentive program to reward providers for delivering excellent preventive care for
cardiovascular health
High risk
Core Quality
Measures
All Patients
Uninsured/
Medicaid
With Diabetes
Diabetes and
Uninsured/Medicaid
Aspirin
$20
-
-
-
Blood Pressure
Control
$20
2X
2X
4X
Cholesterol Control
$20
2X
2X
4X
Smoking Cessation
$20
-
-
-
Example of incentive payment: For a patient with diabetes and who is either Medicaid or uninsured, controlling a
patient’s blood pressure can result in an $80 incentive.
•Average Provider can earn between $10,000 to $20,000
•Maximum cap for any practice is $100,000
What Does the Future Hold?
•
•
•
•
•
Expanding health information exchange
Panel Management Pilot
Patient Engagement
Public Health Reporting
Building a social network
• Becoming a Regional Extension Center
– Stimulus $$
Stimulus
• Authorizes $19B for health IT
– $17B in electronic reimbursement incentives
– $2B for standards development and capacitybuilding
• Providers eligible for $40-65k when submit
data electronically
– Doesn’t solve upfront costs: $24-40k/provider
– Potential to aggravate existing disparities
• Loophole: State-designated extension
centers