hit: replacing the missing link between community health care and public health
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HIT: Replacing the Missing Link Between Community Health Care and Public Health. Neil S. Calman, MD The Institute for Urban Family Health New York City. About the Institute for Urban Family Health. Institute for Urban Family Health 11 Community Health Centers – - PowerPoint PPT PresentationTRANSCRIPT
THE INSTITUTEFOR URBAN
FAMILY HEALTH
HIT:Replacing the Missing Link
Between Community Health Care and Public Health
Neil S. Calman, MD
The Institute for Urban Family Health
New York City
THE INSTITUTEFOR URBAN
FAMILY HEALTH About the
Institute for Urban Family Health
• Institute for Urban Family Health – 11 Community Health Centers – – 7 in Bronx, 3 in Manhattan, 6 in Mid-Hudson Valley– 8 homeless healthcare sites in Manhattan– 2 School based health centers– 2 Family Practice Residency Training programs– 250,000 primary care visits / 105,000 patients
• Fully paperless since September 2002• Epic (Verona, Wisconsin) EHR / PMS
THE INSTITUTEFOR URBAN
FAMILY HEALTH
It is Impossible to Deliver
State-of-the-artHealth Care
without an EHR
1
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Community Health Centers are a Vital Part of our Nation’s
Public Health System
2
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FAMILY HEALTH
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Release
Nu
mb
er o
f C
ases
Symptom Onset Severe Illness
Days
The Benefit of Early Detection of Syndromes
t
THE INSTITUTEFOR URBAN
FAMILY HEALTH Single patient visit yields complex EHR data
• Patient Address• Race / Age / Gender• Medical history
• Provider Location• Reason for visit• Problem list
• Temperature• Height/weight• Respirations
• Procedures• Medications• Lab results• Diagnoses
THE INSTITUTEFOR URBAN
FAMILY HEALTH
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
7/8/03 8/8/03 9/8/03 10/8/03 11/8/03 12/8/03 1/8/04 2/8/04 3/8/04 4/8/04 5/8/04 6/8/04
Per
cen
tag
e o
f fe
ver/
flu
ch
ief
com
pla
ints
0.000
0.010
0.020
0.030
0.040
0.050
0.060
Per
cen
tag
e o
f co
mb
inat
ion
syn
dro
me
Flu isolates
Blue = ER “flu/fever”
Red = Flu “A” isolates
Violet = Flu “B” isolates
THE INSTITUTEFOR URBAN
FAMILY HEALTH
EHR Fever
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
7/8/03 8/8/03 9/8/03 10/8/03 11/8/03 12/8/03 1/8/04 2/8/04 3/8/04 4/8/04 5/8/04 6/8/04
Pe
rce
nta
ge
of
fev
er/
flu
ch
ief
co
mp
lain
ts
0.000
0.010
0.020
0.030
0.040
0.050
0.060
Pe
rce
nta
ge
of
me
as
ure
d t
em
pe
ratu
resBlue = ER “flu/fever”
Purple = EHR Fever >100 F
Red = Flu “A” isolates
Violet = Flu “B” isolates
THE INSTITUTEFOR URBAN
FAMILY HEALTH
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
7/8/03 8/8/03 9/8/03 10/8/03 11/8/03 12/8/03 1/8/04 2/8/04 3/8/04 4/8/04 5/8/04 6/8/04
Perc
enta
ge o
f Fev
Flu
chie
f com
plai
nts
0.000
0.005
0.010
0.015
0.020
0.025
Perc
enta
ge o
f com
bina
tion
synd
rom
e
Fever AND respiratory syndrome
Blue = ER “flu/fever”
Brown = EHR T≥ 100o and
Respiratory Syndrome
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Institute patient fevers peaked 13 days before ER visits for Fever and Flu – this indicates that health center data may be the first “signal” of an impending epidemic.
Patients of the Institute for Urban Family Health
Institute fever data responded to Flu B outbreak-ED data did not
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Community Health Centers can expand knowledge about the community’s
health and use that information to improve its
care of patients
3
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Provider Patient
Cough!
Step 1: EHR institution to public health agency – clinical encounters
IUFH
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
7/8/03 8/8/03 9/8/03 10/8/03 11/8/03 12/8/03 1/8/04 2/8/04 3/8/04 4/8/04 5/8/04 6/8/04
0.00
0.01
0.02
0.03
0.04
0.05
0.06
Step 2: Public health agency to EHR institution - epidemiologic awareness
NYCDOH
1
2
DOH receives signal of outbreak of respiratory illness
Practice Alert in EHR for age < 18 yo, cough/fever requests provider to do full cultures and call DOH for immediate pick-up and ID by DOH lab => message in EHR supports Dx of future pts
Cough
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Few Measurable Quality Improvements Come
from EHRs –Almost All are Facilitated
by EHRs and Cost Real $$$$$
4
THE INSTITUTEFOR URBAN
FAMILY HEALTH
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FAMILY HEALTH
Clinical Decision Support – Impact on Vaccines THE INSTITUTE
FOR URBANFAMILY HEALTH
THE INSTITUTEFOR URBAN
FAMILY HEALTH
HgbA1c Progress
Average A1c for Past 12 Months
7.5
7.55
7.6
7.65
7.7
7.75
7.8
HG
BA
1C
SC
OR
E
THE INSTITUTEFOR URBAN
FAMILY HEALTH
THE INSTITUTEFOR URBAN
FAMILY HEALTH
10 Take New York Indicators
1. Have a Regular Doctor or Other Health Care Provider
2. Be Tobacco-Free3. Keep Your Heart Healthy4. Know Your HIV Status5. Get Help for Depression6. Live Free of Dependence on Alcohol and Drugs7. Get Checked for Cancer8. Get the Immunizations You Need9. Make Your Home Safe and Healthy10. Have a Healthy Baby
THE INSTITUTEFOR URBAN
FAMILY HEALTHIdentify last
recorded quit date and date of last status
update
FORMER SMOKER BPA PATHWAY
Was last quit date within past 2 years
(or null)?
Was last status update < 90 days ago?
Was last update > 12 months ago?
No BPA activated
NO
YES
NO
BPA #4b: "Update Smoking Status"
YES
BPA #4a: "Update Smoking Status"
NO
Clinician clicks status radio button and clicks verify
button
Was current status updated and verified?
NO. BPA not satisfied.
NO
Store status update
verification date.
YES
BPA satisfied
Clinician clicks status radio button and clicks verify
button
Was current status updated and verified?
BPA #4a not satisfied.
NO
BPA #4a satisfied
Relapse prevention counseling in past 90 days OR quit date > 12 months
ago?
STOP YES
YES
BPA #5: "Review relapse prevention
interventions" NO
Congratulation, you've been tobacco-free for ___ days!
Offer relapse prevention literature.Review current treatment plan
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Clinical Decision Support – Tobacco Best Practice Alert
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Patients Seen at Least Once by Their Primary Care Provider
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Men >35; Women>45 Who have had their cholesterol tested
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Men >35; Women>45 Who have had their cholesterol tested
THE INSTITUTEFOR URBAN
FAMILY HEALTHDepression Screen with PHQ2
THE INSTITUTEFOR URBAN
FAMILY HEALTHDepression Screen with PHQ2
THE INSTITUTEFOR URBAN
FAMILY HEALTHRecorded Substance Abuse Hx
THE INSTITUTEFOR URBAN
FAMILY HEALTH Recorded Substance Abuse Hx
THE INSTITUTEFOR URBAN
FAMILY HEALTHPneumococcal Vaccine >65yrs old
THE INSTITUTEFOR URBAN
FAMILY HEALTHPneumococcal Vaccine >65yrs old
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Provider Nutritionist Referral Rate vs. Pts Average HgBA1c
6.5
7
7.5
8
8.5
9
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%
Rate of Nutrition Referral
Mo
st
Re
ce
nt
Hg
bA
1C
22
12
1
9
0.9
THE INSTITUTEFOR URBAN
FAMILY HEALTH
New opportunities emerge to get
information about racial disparities in
health outcomes
5
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Last Hemoglobin A1c by Race
White 7.03
n=423
Black 7.44
n=2122
Latino 7.86
n=1555
Asian 7.12n=76
6.6
6.8
7
7.2
7.4
7.6
7.8
8
HgbA1c
THE INSTITUTEFOR URBAN
FAMILY HEALTH
0
10
20
30
40
50
60
70
80
90
Insulin/SensAgent %
1 HgbA1c % 2 HgbA1c % LDL test %
White
Black
Latino
Asian
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Power to the People
5
THE INSTITUTEFOR URBAN
FAMILY HEALTH
THE INSTITUTEFOR URBAN
FAMILY HEALTH
THE INSTITUTEFOR URBAN
FAMILY HEALTH
THE INSTITUTEFOR URBAN
FAMILY HEALTH
THE INSTITUTEFOR URBAN
FAMILY HEALTH
What will the future bring …?
THE INSTITUTEFOR URBAN
FAMILY HEALTH
Its just the beginning …..