Case Overview: New York City Electronic
Health Record (EHR) Implementation
Source: NYC Tourist
Laura Pitarys
Keio University
March 11, 2014
Main Points
The New York City EHR program’s success:
1. Targeted approach
2. Strong government support in
implementation and funding
3. Public Health objectives
4. Transparency in results
5. Innovative pilots
Agenda
NYC Health Policy Overview
 Primary Care Information Project (PCIP)
Overview
PCIP Mission and Objectives
Addressing Privacy and Security Issues
PCIP Funding and Financing
Evaluations, Results and Challenges
Looking Forward/Next Steps
Hurricane Sandy: October 29, 2012
Source: New York Daily News
$50B damage in the US
117 lives lost
Sources: CDC and NHC
Source: NYC DOHMH
New York City Health Policy
Environment
Health Snapshot
Population
• Roughly 8.3M
residents in 2012
Poverty
• 21.2% of New
York City
residents fall
under the
poverty line in
2012.
Sources: NYC Department of City Planning,, NY Times, United Hospital Fund and NYC DOHMH.
Health Snapshot
Medical Access
• Approximately
1.2M uninsured
in NYC in 2009
Health
• 650,000 NYers
have diabetes
and another 1M
are pre-diabetic.
• 15.5% of adults
smoke.
Sources: NYC Department of City Planning,, NY Times, United Hospital Fund and NYC DOHMH.
Medically Underserved Areas in NYC
Sources: US Dept. of Health and Human Services and New York World
NYC Primary Care Information
Project Overview
Terms
NYC
DOHMH
PCIP
• New York City Department of
Health and Mental Hygiene
• Municipal public health agency
funded by tax payers
• Primary Care Information
Project
• EHR program managed by
DOHMH
Terms
eClinical- • EHR software vendor selected by
DOHMH
Works
RHIO
• Regional Healthcare Information
Organization
• Collaborative groups of providers
working on EHR interoperability.
Terms, cont.
Medicare
• Health insurance for elderly
Americans
Medicaid
• Health insurance for low
income Americans
Terms, cont.
EHR
PHR
• System that has the ability to
connect/interact with other
systems (e.g. EMR, pharmacy,
lab, other EHR, etc.)
• Interface that allows patients
to view their own medical
data and add/modify some
data.
Background
Sponsor
NYC Department of Health
Project
Primary Care Information Project
Policy Advocates
Mayor Bloomberg and Commissioner Frieden
Timeline
2005-present
Program Objective
Addresses Public Health Concerns
Criteria:
The Key to PCIP is Point of Care &
Preventive Care
Diagnosis
Outpatient
Inpatient
Criteria:
Those most in need of medical care
Requirement: Primary Care
providers (outpatient)
Serving low income
neighborhoods, or
Minimum 10% Medicaid (or
uninsured patients), and
Correctional Health facilities
(e.g. Rikers Island jails)
Public Policy Objectives
 PCIP was intended to help improve
preventative care, particularly those at
risk for chronic diseases.
 Areas of health policy concern in NYC
include: obesity, Type II diabetes,
cardiovascular health, high blood pressure
and smoking cessation.
Public Policy Objectives
 The PCIP metrics were aligned with the
public health Take Care New York (TCNY)
core areas (strategic health policy
priorities).
TCNY
PCIP
• Quality
health care
for all
• Be tobacco
free
• Be heart
healthy
• Healthy
neighborhoods
• Exercise &
healthy
eating
• Stop the
spread of
HIV & STIs
• Recognize
& treat
depression
• Reduce
alcohol &
drug use
• Prevent &
detect
cancer
• Raise
healthy
children
EHR Implementation
 NYC Dept. of Health (DOHMH) chose one
EHR vendor for implementation.
 eClinicalworks, the selected vendor, had a
successful track record when
Massachusetts providers were given an
option in the Mass. EHR initiative.
EHR Implementation
Small
Practice EHR
Vendors
Source: IDC Health IT Strategy 2012
Evolution of EHRs
Hospitals, Clinics, other care facilities
(connected through RHIOs)
Specialists
(including behavioral health)
Primary Care Providers for Medically
Underserved
(including Correctional Health facilities)
NYC PCIP Mission and Objectives
PCIP Mission
Patient Centered Approach
Patients are able to see lab results, prescriptions
and make appointments and communicate with
doctor online.
Clinical Quality Improvement
Ability to aggregate data to evaluate the quality of
preventive care as well communicable disease
outbreaks.
Clinical Decision Support
System reads patient data and gives providers
suggested interactions or potential at-risk for
chronic disease.
24
EHR Capabilities
Provider
PCIP
Patient
(PHR)
Pharmacy
Labs
EHR Capabilities Primary
Provider
Hospitals /
Specialists
PCIP
Patient
(PHR)
Pharmacy
Labs
EHR Capabilities
EMR
Claim
PHR
EHR
PM
Labs
Rx
Patient Centered Approach
Patient Centered Approach
Patients are able to see lab results,
prescriptions and make appointments
and communicate with doctor online.
Patients are encouraged to educate
themselves about their health and actively
manage any conditions.
Email communication with doctors is
enabled as are scheduling capabilities and
prescription refill requests.
28
Patient Portal
Account
Information
Intake Forms
Messages
Appointments
Reminders
Requests
Medical
Records
Education
Materials
29
Patient Portal Snapshot
30
Patient Portal Snapshot
31
Patient Portal Snapshot
32
Clinical Quality Improvement
Clinical Quality Improvement
Ability to aggregate data by clinic/hospital to
evaluate the quality of preventive care as well
communicable disease outbreaks.
Pay-for-performance (P4P) based on
effective utilization of the system
Medicine recall alerts: Alerts sent from the
Department of Health to providers through
EHR system.
33
Clinical Quality Improvement
Comparative dashboard reports available to
clinicians by PCIP.
No identifiable patient data is transmitted
to the Dept. of Health!
34
Dashboard
Source: DOHMH
35
Dashboard Details
Source: DOHMH
36
Clinical Decision Support System (CDSS)
Clinical Decision Support
System reads patient medical history and data and
gives medical providers suggested interactions or
potential at-risk for chronic disease.
 Based on clinical and demographic information entered
(e.g. patient with chronic disease), the system requires
prompts for additional questions/information.
 The system stores the answers to prompted questions,
lab results, prescription information and vital signs.
 Alerts for missing data.
37
Clinical Decision Support
An example of the parameters for Type II diabetics is:
 At least 18 years of age and
 Body Mass Index of > 25, > 22 if Asian and
 Pre-diabetes diagnosis (i.e., fasting plasma
glucose: 100-125 mg/dL, oral glucose tolerance
test: 140-199mg/dL, or A1C: 5.7-6.4%)
Source: NYC Department of Health and Mental Hygiene
EHR Results & Effectiveness
Source: NYC Department of Health and Mental Hygiene
EHR Results & Effectiveness
Source: NYC Department of Health and Mental Hygiene
NYC PCIP: Issues of Privacy and
Security
Privacy Issues
HIPAA
• Health Insurance Portability and
Accountability Act of 1996
(Federal Law)
• Sets national standards for
patient security/privacy
HITECH
• Health Information Technology
for Economic and Clinical Health
Act (2009)
• Funding for EHR adoption and
breach laws
Privacy Issues
Security
Privacy
Admin.
Simplific
ation
HIPAA / HITECH
New York State
Public Health
Law also has its
own provisions
on patient
privacy.
Privacy Law Impacts on EHR
Examples of EHR privacy/security setting
from PCIP.
Session TimeOut
Authentication
Lock-Out
Alpha-Numeric
Passwords
Minimum
Length
Passwords
Password
Change
Requirements
and Alerts
SSN not used
as unique
identifiers
Source: New York City DOHMH.
Privacy Law Impacts on EHR, Cont.
Examples of EHR privacy/security setting
from PCIP.
Patient ability
Audit Trails
Role-based
access
Data security
policies
Hardware
security
Source: New York City DOHMH.
to opt-in/out
of HIE
Antivirus
software
Privacy Enforcement
Education
and training
on HIPAA &
HITECH
rules,
appropriate
EHR uses.
Prevention
Maximum
calendar
year penalty
is $1.5M
Annual Max
Fines
Monetary
Fines of
$100 $50,000 per
violation
Data breaches of 500+ must be reported
to media outlets and affected patients.
46
Electronic Consent Forms
In New York, a patient
must opt-in and actively
consent to care.
Source: Housing Works.
NYC PCIP: Funding and Financing
Subsidies: How much and from whom?
The original funding for PCIP was
City Tax Levy ($30M).
Funding Source
City Tax Levy
Purpose
Start-Up; implementation; software and hardware
State
Federal
Interoperability and EHR extension
Private
Medicaid /
Medicare
Other
P4P; evaluations; extension pilots
“Stimulus” funds for interoperability & EHR usage
Incentives and penalties for meaningful use of EHR
Funds that did not make is into the City coffers,
but that are used to support regional EHR
implementation (e.g. State funds, RHIOs, etc.)
Who pays for what?
Item
Initial Hardware
Initial Software
PCIP
√
√
Implementation
Support, Training
On-going
Software fees
√
On-going
maintenance
Internet
connections
Replacement
hardware
Provider
√
√
√
√
Patients pay
nothing for
the system or
access to the
patient portal
Providers pay a
$4,000
contribution to
offset the costs of
implementation
and training.
NYC PCIP: Results, Challenges
and Achievements
EHR Results & Effectiveness
54
Over 4
Million
Patients
Clinics
63 Community
Health Centers
Over 9,000
providers
31 Large Practices
1,064 Small Practices
Note: 3,200 providers and 3+ million patients through initial PCIP program.
Extension programs have reached additional providers.
EHR Results & Effectiveness
Blood Pressure
96,000+ patients reduced their high blood pressure
Diabetes Management
81,000 patients improved their diabetes management.
Smoking
58,000 smokers were given assistance and successfully quit.
Source: NYC Department of Health and Mental Hygiene
NYC EHR: Moving Forward
EHR Interoperability
CCR (XML format):
 Header
 Patient Identifying Information
 Patient Financial and Insurance
Information
 Health Status of the Patient Claims
 Care Documentation
 Care Plan
 Recommendation
EMR
EHR
Patient Matching done by:
 Name
 DOB
PHRGender
 RHIOs have internal unique
identifiers within their systems
PM
Labs
Pharmacy
EMR
EMR
Claims
PHR
Claims
EHR
PM
Labs
Interoperable
Technology
(RHIOs/CCR)
PHR
EHR
PM
Labs
Pharmacy
Pharmacy
EHR Next Steps
 Macroscope Pilot: Using aggregate EHR data to
track chronic diseases in real time and allow
policy makers to react more quickly to changes
trends.
 PEEK (Patient Education and Engagement Kiosk)
Pilot: Tablets in waiting rooms for patients to
access PHRs and educational information.
 Follow-up calls to patients who have certain
conditions and have not seen a doctor in the
recommended timeframe
Success Factors and Challenges
Success
Pay For Performance Incentives
Implementation support and training
Funding to offset risk
Commitment from government
Transparent Results
Success Factors and Challenges
Challenges
Interoperability
Expanding network
Maintaining Data Integrity
Sample Data and Population
Photo: Harvard Magazine
“ . . . Ensuring every New Yorker, regardless of
income, has access to best healthcare possible. We
really can make a difference if we work together.”
- Mayor Michael Bloomberg, 2013
Thank you