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 Primary Care Information Project | 7 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 Primary Care Information Project | 12 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