CHCs and Public Health HIT
Partnerships – The New York
Experience
(addressing common goals, clinical decision
support, public health reporting, public
health alerts, syndromic surveillance)
Joseph Lurio, MD IFH
Winfred Wu, MD, MPH NYC DOHMH
The Institute for Family Health
15 Community Health Centers –
5 Bronx, 4 Manhattan,
6 Mid-Hudson Valley
8 homeless healthcare sites
1 School based health programs
3 Dental centers
2 Community Mental Health Centers
2 Free Clinics
225,000 primary care visits
70,000 patients
NYC DOHMH
• Serves all five boroughs of NYC
• Six Major Divisions
– Disease Control
– Environmental Health
– Epidemiology
– Health Care Access and Improvement
– Health Promotion and Disease Prevention
– Mental Hygiene
• Staff of 6,000
Center of Excellence
in Public Health
Informatics
Project Partners
Institute for
Family Health
NYC
DOHMH
Columbia
University
DBMI
Goals of Collaboration
• Improve
Function of EHR
• Demonstrate
How CHCs can
be integrated
into Public
Health
Infrastructure
Collaborative Projects
Center of Excellence
(2004)
New Projects
(2008 - )
• TCNY
• Syndromic Surveillance
• Immunization Interface
(Bidirectional)
(NYCDOHMH & IFH)
• Medlee natural
language processing
data extraction project
(Columbia)
• Reportable Disease
Notification
• Real Time, Alerts
• Swine Flu Surveillance
• SSTI (Appropriate Skin
Infection Treatment)
• Urine Antibiograms
(Appropriate UTI
Treatment)
Syndromic Surveillance
• Health-related data
preceding diagnosis
(e.g. clinical notes,
absentee rates,
pharm sales) to ID
potential cases
• Changes in signal
may herald
outbreaks
Syndromic Surveillance
Monitor for:
• Influenza Like Illness (ILI)
• GI illness
Data Utilized
• Chief Complaints
• Diagnoses (filed by
provider)
• Vital Signs
–
–
–
–
Temp
Pulse
BP
Resp
• Orders
Syndromic Surveillance – ILI (Broad
Definition)
Two plots of IFH ILI visits
defined by CC of fever vs MT
> 100
NYC ED syndromic
surveillance – CC based
Take Care New York (TCNY) Goals
– Have PCP
– Healthy Heart
• Diabetes Mellitus:
BP/LDL/A1c
• Cardiac Patients:
BP/LDL
– Cancer Screening
• Mammo
• Cervix
• Colorectal
– Diabetes Screening
• Hypertensives
• Hyperlipidemics
– HIV Screening
– Substance Use
• Assessment (Tobacco,
Alcohol, Drugs)
• Smokers Taking meds
• Smoker Quit Rate
• Buprenorphine
Treatment
– Obesity
• BMI Assessment
• Obesity Treatment
– Depression
• Screening
• Reassessment
(Treatment)
Strategy for Achieving TCNY Objectives:
Integration into Clinical Workflow
• Alert: Clinical
Best Practice
Alerts (BPAs)
• Assist:
Hyperlinked
order sets
(SmartSets)
Example SmartSet
6/3
7/30 /20
8/31 /2 06
0
9/31 /2006
10 0 / 06
2
11 /31/ 006
/30 20
12 /2 06
/3 0
1/3 1/2 06
0
2/21 /2006
3/38 /2 07
0
4/31 /2007
5/30 /2 07
0
6/31 /2007
7/30 /2 07
0
8/31 /2007
9/31 /2 07
10 0 / 007
/ 2
11 31/2007
12 /30/ 007
/3 20
1/3 1/2007
2/21 /2 07
0
3/39 /2008
4/31 /2 08
0
5/30 /2008
6/31 /2 08
0
7/30 /2008
8/31 /2 08
0
9/31 /2 08
10 0 /2008
11 /31/ 008
/ 2
12 30/2008
/3 0
1/3 1/2 08
0
2/21 /2008
3/38 /2 09
0
4/31 /2009
5/30 /2 09
1 / 009
20
09
Percentage
Percentage of Women ages 52-69 that
Received a Mammogram
100
90
80
70
60
50
40
30
20
10
0
ALL
Immunization Registry Interface
Immunization Interface: NYC CIR
Immunization Interface: Epic
Immunization Interface
Was it worth all that effort?:
• Lots of Work
to Build
• Lots of Work
to Maintain
Integrating Public Health
Alerts
at the Point of Care
Rapid Response To Emerging
Conditions
Objectives:
• Decrease time to diagnosis
• Opportunity for clinician to identify
and treat rare conditions quickly
• Increase chances for containing an
epidemic
Current State of Public Health
Information Exchange
• Health Alert Network
(HAN)
• MMWR
• Mass media
• Peer-reviewed
literature
• Problem:
Information not
integrated into
clinical workflow
Delivery of Public Health Information via
EHRs
• Enables:
– Integration of information
in the clinical workflow
– Delivery of information in
a specific and contextually
relevant manner
– Collection of additional
• Patient history
• Diagnostic tests
– Up to date treatment (Via
guideline transmittal &
Linked Order Sets)
Alert for Swine Flu
Decision Support
• Public
Health
Notices
(HPN) Good
• Best
Practice
Alerts Better
“It was a dark and stormy night.
Dr. Lurio’s clinic was supposed to
be over at 5PM, but at 6 his
nurse told him there was one
more patient to be seen…”
Notifiable Disease Reporting
• Health providers
mandated to report
notifiable conditions
• Reporting in NYC via
paper or internet (webform)
• Historically low
compliance by providers
– Lack of awareness
• What to report
• How to report
– Time
Improving Reporting With EHRs
• EHRs can facilitate
provider reporting
– Notify provider when
to report
– Provide forms for
reporting
• BPA configured with
hyperlinked
reporting form
Initial Results
Initial Results
Of the 34 patients
where provider
documented
plan to report,
only 6 were
received at
DOHMH!
Next steps: Prepopulated forms specific
to condition being reported
H1N1 Surveillance Project
Using IFH/DOHMH partnership
Opportunity to
address:
•Proportion of
ILI due to H1N1
swine influenza
•Frequency of
severe illness
•Differences
between mild
and severe
illness
H1N1 Surveillance Project
• Community
surveillance project
began on 5/26
• Key partners:
– IFH
– DOHMH
– Columbia University
• Value to public
health and clinical
community
H1N1 Surveillance Project
• Results to Date
Weekly MassTag PCR Results
30
25
Number Positive
– 114 patients
tested since
5/26
– 61 (54%)
positive for
H1N1
– Sensitivity of
rapid test: 28%
(17/61)
H1N1
Flu B
20
RSV
15
HPIV
HMPV
10
CoV
EV/RV
5
0
May 30
June 6
June 13
Week
June 20
Collaboration between DOH and CHC
provides mutual Benefit
• DOH Requires Ambulatory Practices to
act as eyes and arms
• CHCs rely on DOH to provide expert
guidance and situational awareness to
allow effective health care delivery
• Electronic Health Records are a
communication tool that allows this
collaboration to occur.
Special thanks to:
Frances Morrison2, Rachel Berg1, Michael
Buck2 , Winfred Wu3, Kwame Kitson1 Farzad
Mostashari4 , Neil Calman1
1 – Institute for Family Health; 2 – Columbia University; 3 – New
York City Department of Health and Mental Hygiene ; 4- Office of
the National Coordinator for Health IT
Contact information:
Joseph Lurio, MD, FAAFP
Chief Medical Information Officer
Institute for Family Health
Email: jlurio@institute2000.org
Winfred Wu, MD, MPH
New York City Department of Health
and Mental Hygiene
Email: wwu2@health.nyc.gov