Health Records - Children's Health Fund

Making the Most of Electronic
Health Records: A Framework
for EHR-Enhanced Quality
Children's Health Fund
July 10, 2007
Joslyn Levy, BSN, MPH
Director, Clinical Systems Improvement
Bureau of Chronic Disease Prevention & Control
New York City Department of Health and Mental Hygiene
Clinical Systems Improvement
• Improve chronic care management
– Disseminate educational materials and tools to support the
management of key chronic conditions
• Promote adoption of improvement methods and chronic
disease prevention and management strategies
– Provide onsite coaching
• Promote adoption of disease registries and reporting systems
• Promote knowledge transfer and sharing between participating
– Convene collaborative learning forums on chronic conditions
• Address topics such as evidence-based practice and self-management
• Link practices to community resources and NYC DOHMH
Clinical Systems Improvement
NYC Childhood Asthma and Preventive Services
2001 – 2002
21 Peds and FP
Public Health Detailing
2002 - present
236 practices (DPHO)
4066 practices
NYC Diabetes and Depression Collaborative
2003 - 2004
23 IM and FP practices
NYC Diabetes Collaborative – Phase II Spread
2005 - present
3 Institutions
Preventive Services Advisors
2005 - present
8 IM and FP practices
Chronic Disease Training Institute
- Self management goal setting
2006 - present
25 practices
60 + trainings
900 + people trained
Primary Care Information Project
2006 – present
6 Institutions
Clinician’s Toolbox & Self-management Program
(Physicians Foundation)
2007 - present
Start-up phase
Colonoscopy, flu vaccine, smoking cessation, asthma,
diabetes, hypertension, cholesterol, contraception,
depression screening, HIV testing, alcohol screening,
electronic health records
Primary Care Information Project
Increase the quality of care in medically underserved areas
through health information technology (HIT)
PCIP Roadmap
Citywide EHR Network
Citywide Quality Improvement Network
Citywide Health Information Exchange Network
Key Priorities
Safety net providers’ IT Infrastructure
Building population health into EHRs
Learning how to achieve QI with EHRs
Sustainability- “pay for …”
Medical Home
• Care is coordinated & comprehensive
• Care is planned, monitored and measured
• Community based PCPs are active comanagers with specialists
• Children and their families are supported as
partners in care
• Community resources are integrated into
care and community cultures are supported
• Clinics and practices offer phone and easy
office access
QI Principles Supported by eCW
Give the right care at the right time
Everyone gets the care that they need (population management)
Primary caregiver (responsible party) clearly identified
Reports based on current clinical data
Flexible query function for drilling down into a measure
Citywide data available for benchmarking
Care is reliable, coordinated and efficient
Actionable care opportunity reports
Performance feedback is credible and timely
Point of care reminders
Quality dashboard
Evidence-based treatment options for TCNY measures
Linkages to Public Health Information Systems (CIR)
Standardized workflow
Clinical practice expectations clear
Administrative tracking systems
Patients are partners in care
Integrated self-management support
Patients/families provide feedback on the care they receive
eCW Characteristics That
Support QI
Role-based treatment screens
Structured data collection
Field for primary caregiver
Clinical decision support system (CDSS)
Integrated self-management support
Performance feedback reporting
Administrative tracking systems
Role-Based Screens
• Clearly delineate “what needs to be done when and
by whom” and diminish room for error and omission
• Facilitate all staff members working to the maximum
capacity of their licensure and “frontloading” care
• Underscore the importance of the care team
Structured Data Collection
• What
– Entering patient information in a specific field that is
only for that piece of information.
• Why
– Structured data entry makes it possible to retrieve
data when you need it and makes it possible to
generate reports easily. When structured data
elements are entered in narrative section only, data
element will not be counted in report.
• Examples:
– Multiple peak flow readings during one visit.
Primary Caregiver
Provider who provides continuing care of varied medical
conditions, not limited by cause, organ system, or diagnosis
eCW has three provider fields
• PCP (Insurance-related provider)
• Primary caregiver (responsible/accountable provider)
• Rendering provider (provider who takes care of the patient at that
All registry and performance feedback reports will be generated based
on primary caregiver.
Clinical Decision Support System (CDSS)
Asthma Examples
• Point of care reminders (alerts, dashboard, highlighting, etc.)
– Severity assessment required
– Persistent asthma classification consider inhaled corticosteroid
– Smoking cessation counseling recommended
• Interactive forms and order sets
– Severity assessment calculator
– Asthma orders (e.g. prescribe appropriate meds, asthma action
plan, education, referral for specialty care, spirometry)
• Care opportunity reports (actionable)
– Patients overdue for planned care visits
– Patients who will need a flu shot
• Performance feedback reports
– % of patients with severity assessment by practice site
– % of patients with persistent asthma with ICS prescribed by
– A system for collecting and maintaining relevant clinical data for patients to be
used to monitor and improve the care of the population
– Anticipate (who will need a flu shot)
– Prepare (who is coming in for an asthma planned visit and what will they need
during the visit)
– Follow up (who needs follow-up call on their self-management goal)
– Recall (who was discharged from hospital and no follow-up visit within 2 weeks)
– Stratify (who is in greatest need of outreach and support)
– Run standard set of reports on predetermined schedule
– Review and formulate recommendations for follow up (e.g., order test, schedule
– Develop systems for follow-up (phone outreach, mail merges for batched
reminder letters, care management)
– Designated panel manager/care coordinator
– Functions delegated to different members of the care team with one individual
responsible for oversight and coordination of registry functions
– QI department staff
Integrated self-management support
– Self-management goal setting and follow-up tools
– Library of patient education materials in multiple
languages that address varied health literacy &
cultural needs
– Fields for tracking teaching methods used and
documenting patients/families understanding
– Automated formulary checks by insurance coverage
make it easier to ensure that patients get the
medications they can most afford
– Structured medication reconciliation with structured
documentation for reasons for non-adherence
– Patient/family satisfaction assessment tools
– Referral lists for community based organizations
– Patient portal for patients to access to their record &
health information and resources
Performance Feedback
• Uses
– Identify systems issues in need of remediation or duplication
– Identify variation: learn from top performers & provide support to
providers who may be struggling
– Identify areas for focused improvement work
– Identify gaps in knowledge and skills
– Drive and assess ongoing quality improvement work at the
provider, practice and site levels
• Effective feedback depends on
Clear understanding of what the measures represent
Accuracy of reports
Regular and routine dissemination
Availability of meaningful comparison and benchmark data
The spirit in which feedback is provided
The support that is provided for improvement
Administrative Tracking Systems
• Care coordination
– Referral ordered, not arranged (care coordinator
supports referral in MH)
– Referral appointment date at least two weeks ago, no
report received
– Consult reports pending by specialty provider or
– Consult received, not reviewed
• Access to Care
– High priority messages not returned
– Visits to primary care provider as a % of total visits
– Advanced access scheduling measures
What Will Make eCW Work as a Quality
Improvement Tool?
Careful assessment of current practice followed by workflow redesign for key
processes to avoid using a new tool to do everything the old way
Practice consensus on clinical guidelines and expectations
Knowledge and skills training to address gaps
Clear assignment of responsibility and a plan for producing and using registry
Clear assignment of responsibility and a plan for producing and using
performance feedback reports
Consistent use of structured fields for documentation
Accurate primary caregiver assignment
Charting during the patient visit
Follow-through on registry and performance feedback plans
Dedicated time for quality improvement work
PCIP Partner Practices:
Eligibility and Public Purpose
• Care for underserved / vulnerable populations
– Medicaid and uninsured
– DPHO areas (S Bronx, Harlem, Central Brooklyn)
• Participate in public health goals
– Mandatory indicator reporting (automated, confidential)
– Quality improvement (inc. decision support tools)
– Public health interfaces (school health, CIR)
• Financial Commitment
– $4k per provider contribution to QI fund
– Assume all ongoing costs after 2 yr testing phase
What Is Included?
Licenses to “NYC Build” eClinicalWorks
2 years maintenance and support (M&S)
Common data interfaces
On-site training
Quality improvement technical assistance
• Predictable, low ongoing M&S costs
– Less than $1,500 per FTE provider/ yr
For further information
Joslyn Levy
Clinical Systems Improvement
Primary Care Information Project