Moving EHRs Upstream: Lessons
from Bronx-CATCH
Earle C. Chambers, PhD, MPH
Arthur Blank, PhD
Peter Selwyn, MD, MPH
Department of Family and Social Medicine
Albert Einstein College of Medicine-Montefiore Medical Center
June 2015 ROCChe Meeting
Presenter Disclosures
Earle C. Chambers, PhD, MPH
1) The following personal financial relationships with
commercial interests relevant to this presentation existed
during the past 12 months:
“No relationships to disclose”
Objectives
•
To describe the background and rationale for the formation of a multistakeholder partnership between medical, public health, and
community-based institutions to improve the health of communities
in the Bronx, NY (‘Bronx-CATCH’)
•
To describe key initiatives to be undertaken by this partnership
particularly new data collected via EHR and geographic mapping
•
To present selected baseline and preliminary data
•
To describe challenges and successes
•
To share plans for the future
Bronx, N.Y.:
- Ranked last or near-last
in health indicators of
62 counties in NY State
in “County Health
Rankings” report*
- Population = 1.4million
- poorest urban county
in U.S.
*Source: http://www.countyhealthrankings.org/sites/default/files/states/CHR2012_NY.pdf
The Bronx
Current situation - Medical Centers

Medical centers have traditionally focused on improvements in
patient care

Medical centers have not focused on the health of the population

New developments including ACO’s and increasing capitation
are aligned with goals of population health
Current situation – Department of Health

DOHMH increasingly taking on a “policy, systems,
environment” approach

DOHMH has interest and expertise in population-level
interventions specifically for clinical practices

The need is there: no paradigm, structures or sustained
support currently exists for systematically linking work done
“inside” the medical center/clinic to the
environment/neighborhood outside
Opportunity

Community and local environmental change pertaining
to nutrition, physical activity, and healthy behaviors can
have major impact on health outcomes, both for patients
and the broader population

Combined clinical and public/population health data
sources can support more relevant analysis/evaluation of
community health improvement efforts
Bronx-CATCH (“Collective Action to Transform
Community Health”) Mission and Strategy
Mission: To create a high-level partnership between health care,
public health, community-based organizations and other
stakeholders, with the goal of improving the health of local
communities throughout the Bronx.
Strategy:

Locally specific interventions

Stakeholder partnerships

Mixed-methods analytic plan
“Health Promotion Zones”

Located in neighborhoods served by FQHC’s or
similar local primary care centers

Making the work accountable:

Choose important health outcome(s) for which
environment/systems/policy changes are likely or are
proven to make a difference

Develop viable metric(s)

Develop accountability structure

Provide adequate support
Healthy Promotion Zones
Williamsbridge
Family Practice
Family Health
Center
West Farms
Family Practice
Comprehensive
Health Care Center
South Bronx
Health Center
Via Verde
Family Practice
Bronx-CATCH Partners, Target Areas
and Interventions
Partners: Montefiore Medical Center, NYCDHMH, BCHN,
Northeast Bronx Community-Clergy Coalition, housing and senior
centers, youth after-school centers, local schools, Bronx River
Alliance, Bronx Borough President, local elected officials, et al.
Areas of Disease Focus
Obesity/diabetes
• Hypertension/cardiovascular disease
• Cancer
•
Areas of Planned Community Intervention
Food access and nutrition
• Fitness and physical activity
• Smoking cessation and prevention
•
Strategic goal: to develop locally specific intervention plans which are also
generalizable, across the many touch-points of the health care delivery system and
the wider community.
Data already collected and available in EHR:
•
•
•
•
•
•
Race or Ethnicity
Preferred Language
Depression – PHQ2 and PHQ9
Tobacco Use
Residential Address
Census Tract-level US Census data e.g. median income
Data added to EHR through CATCH:
•
Physical Activity
•
Dietary Patterns
Community Health Survey (CHS)
Added expertise:
•
Geocoding
•
Geographic mapping
•
Geographic Information System Analysis
18+ years old
13 to 17 years old
6 to 12 years old
Problems with Year 2 EHR
Survey data
1) Clinical staff bypassing the survey questions
-Skipping some questions
-Bypassing the survey altogether
2) Technical glitches with the EHR form
- ‘random’ popup of survey
Challenges
Successes
• Provider fatigue regarding
questionnaire
• Partnership with local
organizations/stakeholders
• Developing useful feedback to
clinicians
• Incorporation of CHS questions
into EHR + trainings
• Developing tracking mechanisms
within EHR
• Extraction of EHR data +
comparison to neighborhood level
data
• Evaluation of workflow
• Evaluation of specific intervention
elements
• No dedicated staff to oversee data
collection, management, analysis,
and feedback
• Change in hospital priorities over
time + no extra funding
• Change in EHR system (EPIC)
• Implementation of interventions
with preliminary evaluations
underway
What did it take?
Partnership with local organizations/stakeholders
•
Getting buy-in from Health Department and medical directors at clinic sites
helps convince hospital management of importance of measures.
•
DOH runs CHS training sessions at clinics
Incorporation of CHS questions into EHR + trainings
•
Communication with IT Department regarding design of data collection
within the EHR (when to administer, how to bypass if necessary, etc)
•
Consistent testing of validity of data to ensure that accurate data is being
collected (drop down menu vs. write-in fields)
•
Identifying who will ask questions and training of those staff in how to
access questions in EHR and ask them correctly to patients
Extraction of EHR data + comparison to neighborhood level data
•
Are we able to get data out on the back end in a format that is easily
analyzed using our statistical software packages?
•
What are neighborhoods?
Flow of EHR RISK ASSESSMENT data regarding CHS
questionnaire items
Data content director EHIT
Data Manager EHIT
DOH
Data extractor EMR-CHS
Data Dumps EHIT
OCH Senior Team
Director of community outreach
DOH-CHS training
Data extractor- Sybase
OCH site coordinator
OCH sites
Spatial analyst EHR-CHS
Earle Chambers
Director
Director of
of EMR-CHS
EHR-CHS
Office of Community Health –
OCH Data Oversight
OCH site coordinator of EHR directives
What are the results?
Walked or biked more than 10 blocks
in past 30 days, 2013
(Percentage responses to CHS/EHR Questions for Adults Aged 18 and Over)
100
Health Center
UHF neighborhood
Percentage responding ‘Yes’
90
80
70
60
50
40
30
80.3
54.2
80.3
55.7
80.3
78.8
57.5
58.8
80.3
59.6
78.2
67.4
20
10
0
Via Verdeᴬ
(South Bronx)
Comprehensive
Health Care Centerᴬ
(South Bronx)
Williamsbridgeᴮ
(Northeast Bronx)
South Bronx Health
Centerᴬ
(South Bronx)
West Farmsᴮ
(South Bronx)
Family Health Centerᴮ
(Fordham - Bronx
Park)
Note. Data source for UHF neighborhood estimates: 2012 Community Health Survey, NYC Department of Health and Mental Hygiene
ᴬData collection from July to December 2013; ᴮData collection from January to December 2013.
Participation in physical activity/exercise
during past 30 days, 2013
(Percentage responses to CHS/EHR Questions for Adults Aged 18 and Over)
100
Health Center
UHF neighborhood
Percentage responding ‘Yes’
90
80
70
60
50
40
30
80.5
62.4
62.5
71.2
64.4
71.2
66.1
71.2
68.2
71.2
74.3
82.0
20
10
0
Williamsbridgeᴮ
(Northeast Bronx)
West Farmsᴮ
(South Bronx)
Comprehensive
Health Care Centerᴬ
(South Bronx)
Via Verdeᴬ
(South Bronx)
South Bronx Health Family Health Centerᴮ
Centerᴬ
(Fordham - Bronx
(South Bronx)
Park)
Note. Data source for UHF neighborhood estimates: 2012 Community Health Survey, NYC Department of Health and Mental Hygiene
ᴬData collection from July to December 2013; ᴮData collection from January to December 2013.
No servings of fruit and vegetables eaten
yesterday, 2013
(Percentage responses to CHS/EHR Questions for Adults Aged 18 and Over)
100
Health Center
UHF neighborhood
Percentage responding none
90
80
70
60
50
40
30
20
10
31.4
29.1
18.0
18.0
Via Verdeᴬ
(South Bronx)
West Farmsᴮ
(South Bronx)
26.6
18.0
26.9
23.0
28.8
18.0
23.0
20.8
0
South Bronx Health Family Health Centerᴮ
Comprehensive
Centerᴬ
(Fordham - Bronx
Health Care Centerᴬ
(South Bronx)
Park)
(South Bronx)
Williamsbridgeᴮ
(Northeast Bronx)
Note. Data source for UHF neighborhood estimates: 2012 Community Health Survey, NYC Department of Health and Mental Hygiene
ᴬData collection from July to December 2013; ᴮData collection from January to December 2013.
One or more sugary drinks consumed
on average per day, 2013
(Percentage responses to CHS/EHR Questions for Adults Aged 18 and Over)
100
Health Center
UHF neighborhood
Percentage responding 1 or more
90
80
70
60
50
40
30
20
53.4
41.4
48.3
41.4
48.3
41.4
42.5
37.1
41.1
41.4
33.3
39.8
10
0
Via Verdeᴬ
(South Bronx)
West Farmsᴮ
(South Bronx)
South Bronx Health Family Health Centerᴮ
Comprehensive
Centerᴬ
(Fordham - Bronx
Health Care Centerᴬ
(South Bronx)
Park)
(South Bronx)
Williamsbridgeᴮ
(Northeast Bronx)
Note. Data source for UHF neighborhood estimates: 2012 Community Health Survey, NYC Department of Health and Mental Hygiene
ᴬData collection from July to December 2013; ᴮData collection from January to December 2013.
Where do we go from here?
•
Collaborate with other Montefiore departments where work and expertise
can be shared.
•
Office of Community and Population Health
•
Institute for Clinical and Translational Research (ICTR) Biomedical
Research Informatics Core
•
Clinical IT Research and Development
•
Continue to build research agenda to guide data collection and broader
dissemination of results
•
Analysis of first several sites’ experience will inform plans to expand
program model to other clinical/community locations.
•
Revisit metrics and revise based on new priorities and timeframe
(population comparisons, repeated measures)
•
Use geographic mapping to identify high risk areas (hotspots) where
interventions can be targeted
Continue to link primary care and population
health using evidence based medicine
YDPP Form in EHR
YDPP Referral Program
Referral form in EHR
•
Offered to pre-diabetic
patients at local sites
•
Referral incorporated into
EHR
•
Follow-up with YDPP
program staff
CHI Impact of SBP Data Collection:
Perspectives from the Boston Medical Center
Department of Pediatrics’
Utility Shut-Off Protection Campaign
Moving EHRs Upstream
AAMC ROCChe Virtual Meeting
June 18, 2015
Samantha Morton, JD
Executive Director
MLP | Boston
© 2015 MLP | Boston
MLP | Boston
We equip healthcare, public health and social services
teams with legal problem-solving strategies that promote
health equity for vulnerable people:
•Capacity-building (trainings, toolkits)
•Legal “Triage” (rapid access to consultation)
•Legal “Surgery” (panel of 20+ law firm/in-house partners)
•Technical assistance re: SDOH systems re-design and
policy change
© 2015 MLP | Boston
Key History
•Founded in BMC Pediatrics in 1993
•Became independent in 2012
•Gave rise to National Center for MLP, now sited at
GWU Milken Institute School of Public Health
www.medical-legalpartnership.org
– Medical Director = Megan Sandel, MD, MPH (BMC), who also
serves as Principal Investigator for Children’s HealthWatch
•Recent HRSA classification of civil legal aid as an
“enabling service” for CHCs
© 2015 MLP | Boston
Cambridge Health Alliance
Children’s Hospital Boston,
Martha Eliot Health Center
Dana-Farber Cancer Institute
Hallmark Health System
MA Department of Public Health
Current Partners
Metro North Regional Employment
Board
Mount Auburn Hospital
Steward Health Care System
Good Samaritan Medical Center
Saint Anne’s Hospital
Boston Medical Center
(Geriatrics, OB-GYN, Pediatrics,
Women’s Health/Oncology)
The Children’s Trust /
Healthy Families Massachusetts
© 2015 MLP | Boston
Why Try to Improve Provider
Engagement with Patient Requests for
Utility Shut-off Protection Letters?
© 2015 MLP | Boston
This was not a typical screening gap
• High volume of requests for medical certifications
absent systematic provider screening mechanism
• Disconnects between patient, provider, and systems
– Harms to patient-families (losing heat and lights,
related health impacts, e.g., sickle cell crises)
– Work flow challenges, role confusion for providers
– Negative impacts on provider-patient relationship
© 2015 MLP | Boston
Designing a thoughtful intervention
• Buy-in from critical hospital stakeholders
–Boston Medical Center Grow Clinic, Food Pantry
–Children’s Health Watch
–Pediatric Primary Care
• Effective leadership, including:
–JoseAlberto Betances, MD
–Megan Sandel, MD, MPH
“When you have a large urban clinic like ours that sees
more than 24,000 families―most of whom will qualify for
government protections for low-income families―you just
have a huge volume of families who need this,” explained Dr.
JoseAlberto Betances at the time.
© 2015 MLP | Boston
“If my low-income patients with chronic disease
are forced to make difficult budget choices,
the last thing I want is for them to worry about
whether their power is going to stay on.
Shut-off protection is one way I know
I can help a parent who’s struggling to
meet his or her families’ living needs.”
― Dr. Megan Sandel
© 2015 MLP | Boston
The Intervention (2006-08)
• Training by MLP | Boston advocates
–Addressed various screening strategies
–Included hosting of “Utilities Awareness Weeks”
–Development of Utility First-Aid Kit
and related model Utility Access Policy for the institution
• Integration of Shut-off Protection Letter template and
related guidance on EHR
–“Horses” – more readily resolvable by provider team
–“Zebras” – referred to MLP | Boston “Energy Clinic” for more
intensive evaluation
• Ability to connect patients with complex utility service
problems to advocacy as needed
© 2015 MLP | Boston
Impacts: Patient Level
• 2005-06: BMC Pediatrics signed 193 shut-off protection
letters
• By 2007, BMC Pediatrics was generating 80% more
such letters for patient-families
• In 2008-09, Department generated 676 such letters –
a 350% increase from baseline
© 2015 MLP | Boston
Impacts: Provider Level
• Better understanding of context in which patients make
these letter requests, and the role providers are
expected to play under current public policy
• Improved work flow – centralized access to templates
and related forms on EHR
• Data-driven engagement with the issue, including ability
to track letter generation via EHR
© 2015 MLP | Boston
Impacts: Population Level
• Learning from this campaign synergized with a timely
MA DPU (Department of Public Utilities) review of its
regulations
• We engaged intensively with regulatory review process
– supplied expert, joint medical-legal testimony citing data from this
effort that informed regulatory changes adopted in late 2008
– developed strategic alliances with National Consumer Law Center
and Action for Boston Community Development in this process
• Patients-to-Policy trajectory was realized, helping
thousands of low-income patient-families across the
state better meet their energy needs
© 2015 MLP | Boston
Ensuing State-Wide Policy Change
• Onerous re-certification process for patients and providers
 relaxed illness re-certification requirements for
many categories of ill patients
• Absence of protections for key vulnerable populations
 new eligibility for households with infants
and adults 65+
• Antiquated understanding of healthcare actors (MD only)
 now MDs, NPs, and PAs may sign letters
© 2015 MLP | Boston
Data, Policy, and CHI: A Key Lesson
• At the policy level, the medical voice was influential. In
its written explanation of the changes, the DPU cited the
joint medical-legal comments:
–In D.P.U. 08 4, the Department heard testimony that loss of
utility service is hazardous to the health of children. D.P.U.
08 4 (Medical-Legal Partnership | Boston Initial Comments at
1).
–In D.P.U. 08 4, the Department heard testimony that
allowing only a registered physician or local board of health
official to certify and renew the certification of a serious
illness, combined with the frequency that renewals are
required, has created a significant backlog in medical offices.
D.P.U. 08 4 (Medical-Legal Partnership | Boston Comments
at B).
© 2015 MLP | Boston
Positive Sequelae
• Ongoing innovation and research at BMC re: how best to connect
patients with “concrete supports” like utility service
• Project DULCE
–Robert Sege, MD, Ph.D et al. Medical-legal strategies to Improve Infant
Heallthcare: A Randomized Trial. Pediatrics (July 2015) (published online June 1, 2015)
–Intervention = Family Specialist backed by MLP | Boston and Healthy
Steps
–Faster access to concrete supports (including utility service), lower
ED utilization, better rates of on-time preventive care and
immunizations
• Other innovative health equity research underway with MLP |
Boston via BMC Pediatrics/Addiction Medicine, OB-GYN, and
Women’s Health/Oncology
© 2015 MLP | Boston
Active MLP | Boston Health Equity
Research Participation with BMC
• Addiction Medicine / Pediatrics / OB-GYN
– Evaluating MLP-backed Family Specialist intervention for women in
methadone-assisted treatment with infants
(PI = Ruth Rose-Jacobs, Sc.D)
• Women’s Health/Cancer Care
– Contrasting standard patient navigation services for newly
diagnosed cancer patients with MLP-backed patient navigation for
the same population (PI = Tracy Battaglia, MD, MPH)
• OB-GYN
– Contrasting standard of care for pregnant women confronting a
high degree of social risks with an MLP-backed birth coach model
for the same population (PI = Julie Mottl-Santiago, CNM, MPH)
• All in RCT (randomized controlled trial) context
© 2015 MLP | Boston
References
• Megan Sandel, et al. The MLP Vital Sign: Assessing and
Managing Legal Needs in the Healthcare Setting. Journal of
Legal Medicine, Vol. 35, Issue 1 (2014): 41-56.
• Megan Sandel, et al. Medical-Legal Partnerships: Transforming
Primary Care by Addressing the Legal Needs of Vulnerable
Populations. Health Affairs 29, No. 9 (2010): 1697-1705.
• Utility Access and Health: A Medical-Legal Partnership Patientsto-Policy Case Study (2010). Joint publication of the National
Center for Medical-Legal Partnership and Medical-Legal
Partnership | Boston, available at
http://www.mlpboston.org/results/mlp-boston-publications
© 2015 MLP | Boston
Thank you . . .
. . . for thinking deeply about research efforts that will
meaningfully acknowledge The Whole Patient and
improve health equity!
© 2015 MLP | Boston
Copyright Statement
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nothing in it should be construed as legal advice.
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