Public Health and Improved Primary Care
Sarah Shih, MPH
Exec. Dir. Of Healthcare Quality Information
June 27,, 2010
Primary Care Information Project
NYC D
Department
t
t off H
Health
lth & M
Mental
t lH
Hygiene
i
Primary Care Information Project
Primary Care Information Project | 1
Leading Causes of Death in New York City, 2008
Ischemic heart disease
Lung cancer
Pneumonia & inf.
Diabetes mellitus
Chronic lung disease
Cerebrovascular
Colon cancer
Breast cancer
HIV/AIDS
Accidents
Psychoactive substance
Prostate cancer
Homicide
Suicide
Alcohol
15,475
2,908
2,300
1,643
1,605
1 512
1,512
1,419
1,102
1,073
1,044
865
720
558
473
210
0
2 000 4,000
2,000
4 000 6,000
6 000 8,000
8 000 10,000
10 000 12,000
12 000 14,000
14 000 16,000
16 000
Deaths
Source: Summary of Vital Statistics, NYC, 2008
Primary Care Information Project | 2
National Estimates of Deaths Averted
25000
Number off Deaths Prrevented
20000
Hypertension
Control
80% for all services, potential
reduction of 53,000 deaths
Control of BP from 65% to 80%
could avert ~10
10,000
000 deaths
yp p
Hyperlipidemia
Treatment
Aspirin
Prophylaxis
15000
10000
Colonoscopy
5000
Mammography
P
Pneu.
& IInf.
f Vacc.
V
Papanicalou
0
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
Percent Eligible Utilizing Service
* Cause-specific model results: estimated number of additional deaths prevented before age 80 by increasing utilization of
selected clinical preventive services to varying levels
* Farley TA, Dalal MA, Mostashari F., Frieden TR, Am J Prev Med. 2010 Jun;38(6):600-9
Primary Care Information Project | 3
We know what’s achievable…
Madvig P. Crossing the Quality Chasm: Cardiovascular Care, Kaiser Permanente, 2008
Primary Care Information Project | 4
“The Quality World is Flat”
- NCQA,
NCQA State of Health Care Quality Presentation
Presentation, September 2009
For the past 3 years no statistically significant increase for:
57% of quality measures for Commercially insured
64% of quality measures for Medicaid insured
86% of quality measures for Medicare insured
Primary Care Information Project | 5
HEALTH
INFORMATION
SYSTEMS
that are oriented
t
toward
d prevention
ti
Health Care
that Maximizes Health
REDESIGNED
PRACTICE
WORKFLOWS
PATIENT ENGAGEMENT
that highlights prevention
Frieden TR and Mostashari F, JAMA. 2008;299(8):950-952.
PAYMENT
that rewards disease
prevention and the
effective management
of chronic disease
Primary Care Information Project | 6
EHR Implementation in Primary Care Settings in NYC
Enrollment Count in PCIP
Practices
Providers
Hospitals
5
810
CHCs
37
764
Small
practices
p
433
963
1
70
475
2,537
Correctional
Health
y
Facility
Total
2 018 “li
2,018
“live”
”
Goal for 2012
4 500 “live”
4,500
live and in use
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Primary Care Information Project | 8
BRINGING THE RESOURCES OF LARGE NETWORKS TO
INDEPENDENT SMALL PRACTICES - A “VIRTUAL NETWORK”
Virtual Integrated Health Systems
Integrated Health Systems
Primary Care Information Project | 9
WE’VE MADE OVER 1,600 ONSITE VISITS TO PRACTICES TO ASSIST
WITH WORKFLOW REDESIGN
QI visits
EMR visits
Billing visits
1200
1000
800
1 018
1,018
600
332
269
400
200
0
Q1
Q2
Q3
Q4
Q1
Q2
Q3
2009
2008
10
Q4
Q1
2010
Primary Care Information Project | 10
Potential Health Impact of Take Care New York Measures
500 providers reaching the following targets (80%)
(80%), over a decade
decade,
could prevent premature deaths*
ABCS
Service
Estimated # Deaths Averted
Lipid screening, treatment, and control
1,900
Hypertension identification, treatment, and control
1,800
Tobacco use screening and brief counseling
900
A ii
Aspirin
400
Pneumococcal immunization
300
Colonoscopy and care of positives
260
Influenza immunization
210
Mammography screening and care of positives
100

Focusing on CVD-related TCNY measures can have a significant impact on the health
of New Yorkers compared to other targets.
*Based on peer-reviewed research and, where available, NYC-specific data.
Primary Care Information Project | 11
Pilot Pay-for-Quality
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Lessons Learned and Preliminary Findings
• Attracting Providers to Adopt Electronic
Records and Health IT
• Provider Productivity
• Documented Preventive Service Rates
g use of EHR
• Tracking
Primary Care Information Project | 13
Preliminary Findings and Lessons Learned
Persistent and Multi-Strategy Outreach to Providers
250
40.0
236
Days to recruit
37.7
Number of Outreach Attempts
Yield (Enrolled/Eligible)
35.0
200
30.0
169 3
169.3
149.6
25.0
150
20 0
20.0
101.3
96.6
100
13.5
15.0
14.1
12.0
10.0
50
6.2
13
19
17
50
5.0
22
10
0
0.0
Community Leadership
Health Plan Rebate
RHIO Subsidy
Private Donation
General PCIP Subsidy
Primary Care Information Project | 14
Preliminary Findings and Lessons Learned
Provider Productivity Trends
12.00
10.00
Units or Encounters p
per Provider-Day
March 2006
Start of EHR
Implementation
Sept. 2006
End of EHR
Implementation
April 2007
Start of P4P
8.00
6.00
4.00
Pre-EHR
Post-EHR
Post-P4P
Impl
2.00
RVU Work per Provider Day
Number of Encounters per Provider Day
0 00
0.00
Jan-05
Jul-05
Jan-06
Jul-06
Jan-07
Jul-07
Jan-08
Jul-08
Jan-09
De Leon S, Shih SC, Connelly-Flores A and Mostashari F. J Practice Management, May-Jun 2010
Primary Care Information Project | 15
Data Validation – Preliminary Results
“B i i M
“Bringing
Measurementt tto th
the P
Point
i t off Care”
C ”
AHRQ funded project grant no. R18HS17059
Purpose:
• Assess location of documentation in EHR and it’s impact on quality
measures
• Assess impact of Clinical Decision Support System (CDSS)
Method:
• Sample of Practices (currently have ~30, target is 60)
• Manual review of electronic records
0‐6 months
3‐18 months
EHR
Go‐live
Before CDSS is turned on
After CDSS is turned on
CDSS
Primary Care Information Project | 16
Preliminary Data – Documented Preventive Services
436
390
916
794
1462
1198
268
212
382
338
974
786
2412
1913
Primary Care Information Project | 17
Preliminary Data – Documented Preventive Services
Measure
Antithrombotic Therapy
Blood Pressure Control
Cholesterol Control
Smoking Cessation Intervention
A1c Control
Breast Cancer Screening
Body Mass Index (BMI)
Review
Period
1
2
1
2
1
2
1
2
1
2
1
2
1
2
No. of Patients
per Practice
Practice
Rate
Mean
Min Max
Min,
Mean
Min Max
Min,
15.6
13.9
32 7
32.7
28.4
52.2
42 8
42.8
9.6
7.6
13 6
13.6
12.1
34.8
28.1
86.1
68.3
2, 51
2, 53
4 80
4,
5, 76
18, 97
21 95
21,
1, 25
1, 22
2 32
2,
2, 33
10, 73
8, 47
46, 132
39, 106
41.3%
49.8%
45 7%
45.7%
55.0%
37.8%
52 0%
52.0%
35.9%
32.8%
23 2%
23.2%
38.4%
18.1%
27.1%
60.6%
74.9%
0%, 86.3%
0%, 100%
15% 77
15%,
77.8%
8%
33.3%, 86.5%
0%, 71.1%
0% 77
0%,
77.1%
1%
0%, 100%
0%, 100%
0% 66
0%,
66.7%
7%
0%, 80%
0%, 55.8%
0%, 70.5%
0%, 97.5%
2.9%, 100%
Primary Care Information Project | 18
Where are providers documenting Smoking Status?
Structured fields; Captured
in automated quality reports
and transmissions
Population
2434
Smoking Status
Recorded
Yes 1949
(80.1%)
Current Smoker 268 (11.0%)
Smart Form
130 (5.3%)
Social History 133 (5.5%)
Other
5 (0.2%)
No 485
(19.9%)
Non-Smoker 1681 (69.1%)
Smart Form 663 (27.2%)
Social History 927 (38.1%)
Not Specified
54 (2.2%)
Other
29 (1
(1.2%)
2%)
Patient Docs
4 (0.2%)
Medical History
4 (0.2%)
Non-structured fields; Not
captured in automated quality
p
and transmissions
reports
Primary Care Information Project | 19
Population
2434
Where are providers documenting
Cholesterol Control?
Dyslipidemia
Diagnosis
Yes
761 (31.3%)
Problem List 583 (24.0%)
LDL Recorded
Yes
L b
Laboratory
t
168 (6
(6.9%)
9%)
362 (14.9%)
Patient Docs
Other
HPI
Not Specified
No
No
Medical History
Assessment
HPI
Other
Chief Complaint
1673 (68.7%)
162 (6.7%)
10 (0.4%)
3 (0.1%)
2 (0.1%)
(0 1%)
1 (0.0%)
221 (9.1%)
187 (7.7%)
5 (0.2%)
1 (0.0%)
1 (0.0%)
Primary Care Information Project | 20
WE HAVE A LOT OF WORK TO DO BECAUSE WE KNOW IT DOESN’T
HAPPEN NATURALLY
Preliminary Results
Primary Care Information Project | 21
By bringing this health technology to New Yorkers, we are building a national model for a
health care system that works, by preventing illness rather than merely treating people
y already
y sick.
after they're
Mayor Michael Bloomberg 2/25/08
Primary Care Information Project | 22
Q
Questions?
ti
?
Contact:
C
Visit:
sshih@health.nyc.gov
hih@h l h
www.nyc.gov/pcip