The Primary Care Information Project

1
The Primary Care Information Project

• Sarah Shih, MPH
• Exec. Dir. Healthcare Quality Information
• New York City
• Department of Health and Mental Hygiene
• sshih_at_health.nyc.gov

http//www.nyc.gov/pcip
2
NYCs Health Agenda

• Take Care New York
• Have a Regular Doctor or Other Health Care
  Provider
• Be Tobacco-Free
• Keep Your Heart Healthy
• Know Your HIV Status
• Get Help for Depression
• Live Free of Dependence on Alcohol and Drugs
• Get Checked for Cancer
• Get the Immunizations You Need
• Make Your Home Safe and Healthy
• Have a Healthy Baby

3
Health Care that Maximizes Health
PATIENT ENGAGEMENT that highlights prevention
4
Focused on Medically Underserved Patients in NYC
We have secured signed commitments from 2,100
providers in 379 practices and at 480 sites
1 new provider goes live on the EHR every day
Practices Live In Progress Practice IS ratio
Small Practices 247 96 861
Health Centers 18 13 151
Hospital OPDs 3 2 41
Sub-total 268 111
Practice with sites both live and in
implementation
5
BRINGING THE RESOURCES OF LARGE NETWORKS TO
INDEPENDENT SMALL PRACTICES - A VIRTUAL NETWORK
NYC PCIP
Kaiser Permanente
5
6
PCIP, eCW Practice team structure
PCIP eCW Practices Practices
Small Large
Implementation specialists Project Managers, Business Analysts, SAMs Providers, Office Managers Project Management Team
Infrastructure team Technical Specialists IT Consultant IT Department
Interface Coordinator (PM, labs and CIR) Lab Interface team Providers, Office Managers IT Department, Ref/In-house lab
Quality Assurance Development team Providers, Office Managers Site Administrators
Quality Improvement consultants, Super Users, Billing consultants Trainers, Billing Specialist, Business Analyst Providers, Office Managers, Biller Quality Improvement Unit, Financial Dept.
Privacy and Security consultants Development team Providers, Office Managers IT Department, Legal
Development team Development team Providers, Office Managers Super Users
7
8 Key Features of the TCNY Build
QUICK ORDERS One-click ordering of recommended
preventive services
MEASURE REPORTS Side-by-side provider comparisons
of performance on quality measures
5
1
COMPREHENSIVE ORDER SETS Displays best practice
recommendations (e.g., for meds, labs, patient
education)
ENHANCED REGISTRY Identifies patients by
structured data (e.g., diagnoses, drugs,
labs, demographics)
2
6
eMedNY With patient consent, displays 90-day
history of all Rxs filled by Medicaid patients
AUTOMATIC VISUAL ALERTS Highlights abnormal
vitals
3
7
CDSS Automatically displays preventive service
alerts that are suppressed when addressed
CIR and School Health Sends information to City
Immunization Registry and generates school health
forms
4
8
8
Small Practice Consulting Approach
9
Following Medical Home and Chronic Care Models

• Useful framework for organizing QI work
• Actionable curriculum consisting of a collection
  of discrete activities and achievable goals
• Focus on whole-practice redesign (e.g. teamlet
  care C. Sinsky)
• Provide actionable and meaningful feedback
• View EHR-derived quality measure data on a
  routine basis
• Provides incremental recognition
• BOOTS ON THE GROUND
• Assist practices through the process and lower
  the activation energy
• Software, QI, EMR consulting, Pay for
  Performance, relationships
• Partnership with NCQA- multi-site survey
• Keep practices focused on care and reduce
  administrative burdens
• Average physician spends 68,274 per year
  interacting with insurance plans
• Focus practices on areas to have the highest
  impact for health
• Provide share resources to practices (care
  coordinators, nurses, panel managers)
• Conduct patient outreach using the data from HER
• J. A. Sakowski, J. G. Kahn, R. G. Kronick et
  al., "Peering into the Black Box Billing and
  Insurance Activities in a Medical Group," Health
  Affairs Web Exclusive, May 14, 2009, w544w554

9
10
How do we know whether providers are meaningfully
using the EHR?

• PCIP staff
• Scheduled on-site visits
• Demo of registry query functions
• Data Transmissions from EHR
• Encounter information from PM
• Utilization of EHR metrics
• Quality Measures (EoC)

11
Average Encounters Per Month by Practice Size
Limited to small practices that have been on the
EHR for 6 months or more. Data available on
116 small practices
12
PCIP Contractual Expectations with Providers
Selected Measures for Demonstrating Use of EHR

• Visits where office visit CPT codes were entered
  into the progress note.
• Visits where an order set was used as part of the
  progress note.
• Visits where a smart form was used as part of the
  progress note.
• Visits where blood pressure was entered into the
  progress note.
• Visits where allergy data was entered in a
  structured format
• Insurance claims created over total number of
  insurances for patients that month
• Visits where medications were prescribed through
  the EHR
• Prescriptions entered into the EHR that were sent
  via fax or electronic interface
• Labs reviewed over labs ordered
• Current medications were entered or verified in
  the EHR
• Months in a 6 month period when required data
  files were transmitted to the DOHMH
• Months in a 6 month period when all core
  utilization measures were reported to the DOHMH

13
Proposed Meaningful Use MeasuresOverlapping with
Data Transmitted to PCIP
Line 2011 Measures (Draft from HITECH) Level
9, 10 of permissible RX's transmitted electronically Provider
21,22 lab results incorporated into EHR in coded format OP,IP Practice Provider
26 of encounters for which clinical summaries were provided OP, IP Provider
28 of encounters where med reconciliation was performed OP, IP Practice
30 Report up-to-date status for childhood immunizations OP Practice
31 reportable lab results submitted electronically IP Practice
14
EHR Utilization Transmitted to PCIP

• Snapshot of monthly activities
• Number of practices with EHR use data
• 133 practices in July and August 2009
• 85 have been using EHR for 8 months or longer

EHR use transmissions Total Jul Total Aug
Lab results transmitted 48,072 52,183
Lab results reviewed 56,731 63,882
Use of Medicaid State Rx Claims 2,422 2,560
Active patients 508,079 516,283
limited to practices on the EHR for 8 months or
longer
15
Proposed Meaningful Use MeasuresCurrently within
PCIP Quality Measures
Line 2011 Measures (Draft from HITECH)
1 diabetics with A1c under control OP
2 of hypertensive patients with BP under control OP
3 of patients with LDL under control OP
4 of smokers offered smoking cessation counseling OP, IP
5,6 of patients with recorded BMI OP
14 of patients over 50 with annual colorectal cancer screenings OP
15 of females over 50 receiving annual mammogram OP
16 of patients at high-risk for cardiac events on aspirin prophylaxis OP
17 of patients with current pneumovax OP
19 eligible patients who received flu vaccine OP
Note Quality Measures are collected at the
provider level and stratified by insurance type.
For some practices, stratified by race/ethnicity,
though few providers are completing the field for
race/ethnicity
16
Preliminary Data Quality Measures
Mar08 to Feb09 Mar08 to Feb09 Mar08 to Feb09 Aug08 to Jul09 Aug08 to Jul09 Aug08 to Jul09
Measure Name N Mean (std) Sum N Mean (std) Sum
A1C control (lt 7) 12 53.7 (16.6) 492 44 47.2 (17.0) 2,498
Antithrombic Treatment 58 47.5 (21.2) 8,617 89 49.6 (21.3) 13,686
Asthma control (5-11 yrs) 3 87.8 (18.4) 49 4 89.0 (12.4) 104
Asthma control (12-17 yrs) 2 74.1 (16.4) 22 3 90.6 (8.4) 54
Asthma control (18-56 yrs) 2 45.7 (36.4) 12 11 61.9 (27.5) 105
Body Mass Index 86 61.6 (29.8) 83,029 110 70.4 (26.9) 126,842
BP Control 130/80 DM 56 23.9 (13.5) 4,922 78 30.7 (17.3) 7,358
BP control 140/90 HTN 63 48.6 (16.4) 12,305 85 51.9 (16.0) 18,480
BP Control 140/90 IVD 32 67.4 (16.3) 650 46 69.7 (20.1) 868
Cholesterol Control lt100 gen pop 14 63.4 (22.5) 573 48 52.2 (21.3) 3,145
Cholesterol Control lt100 IVD,DM 15 65.3 (18.5) 874 37 62.4 (15.7) 1,879
Breast cancer screening 16 4.5 (5.8) 6,346 51 5.2 (7.9) 22,034
Colorectal cancer screening 8 1.9 (1.3) 4,126 46 3.9 (6.2) 22,008
Influenza vaccine (over 50) 48 22.6 (18.4) 25,550 70 15.6 (15.2) 38,431
Pneumococcal vaccine 66 9.8 (13.0) 27,352 98 9.8 (13.5) 45,641
Smoking cessation intervention 45 19.0 (14.5) 4,798 79 29.7 (23.6) 8,253
A population estimate was derived by summing
across practice denominators per measure
17
Questions?

• Contact sshih_at_health.nyc.gov
• Visit http//www.nyc.gov/pcip