1 Host Site: County of San Diego, Public Health Services, Health and Human Services Agency Location: San Diego, CA Primary Mentor: Thomas R. Coleman, MD, MS Chief, Maternal, Child and Family Health Services, County of San Diego Secondary Mentor: Deirdre Browner, MPH Epidemiologist II, County of San Diego Fellow s Workplace Support: The County of San Diego has a longstanding history of fostering collaborative opportunities for its staff and trainees. Through the Communities Putting Prevention to Work and Community Transformation Grant efforts, there were numerous policy, systems, and environmental change interventions implemented via the social ecological model to impact chronic disease. And a "Health in All Policies" approach is uniformly recognized and utilized, so successful prior efforts incorporating education, business, transporation, community-based organizations, and other partners have been undertaken. These efforts will be amplified by the newly-funded State and Local Public Health Actions to Reduce Obesity, Diabetes, and Heart Disease and Stroke (1422) activities, which will further strengthen the integration between public health and the primary care sector, with explicit incorporation of health system interventions and clinical-community linkages for hypertension management and diabetes prevention at the community level. The Fellow will learn with and from many other disciplines (e.g., pharmacists, other care team members, community health workers) outside of the traditional public health realm. And our pivotal clinical partner, Be There San Diego, is headed by a master's-prepared social worker who spent many years in the Community Health Center environment. Finally, the Maternal, Child and Family Health Services Branch in Public Health Services embraces teamwork and is structured for optimal interactions among teams within our organization, as well as our external partners. The Fellow will be provided their own office cubicle located within the Maternal, Child and Family Health Services Branch. This workstation will have a computer, , network access with strong IT support, phone, and availability of network printers. This cubicle will be located within the same office as the Primary and Secondary Supervisors, providing easy access to both. The Epidemiology and Immunization Services Branch is also in very close proximity within the same building for optimal collaboration. San Diego County has a wealth of health-related data sets including traditional vital records data, inpatient data, medical examiner, emergency department, immunization registry data, as well as the Local Health Department dataset from the California Health Interview Survey. We use SAS, SPSS, R, and other tools for data management and statistical analysis; the Fellow will have a computer with SPSS and R. We have a supportive workplace environment with professional staff including medical epidemiologists, epidemiologists, and biostatisticians. We also collaborate frequently with academic partners from our
2 local universities, which include both a school of public health and a medical school. We work closely with our health care community and with researchers from the private sector. Community Engagement Partners: Be There San Diego San Diego State University Institute for Public Health Project 1 Title: Expansion of Chronic Disease Surveillance (Phase 2) This project will build on current work engaging the clinical sector in chronic disease surveillance efforts. The County has initial funding and resources to develop a pilot with a large Community Health Center (CHC) to demonstrate the benefit and utility in utilizing EHR data for surveillance. By mid-2015 we anticipate that the first set of expanded data use agreements and any needed governance documents will have been developed, data elements will have been identified, and the first data set will have been sent to the County s Chronic Disease and Health Equity Unit for cleaning and analysis. This effort will be expanded in to bring on three additional CHCs to build support and momentum. This project will also include developing sample chronic disease reports (snapshots) to provide participating clinics with information on their patient population and provider performance. Demonstrating the utility of this data as well as the strength of the analytic tools used by public health will be critical as the County works to build a more collaborative relationship with community clinics and the clinics look to public health as a source for expertise in promoting both patient and community health. Fellow s Project Role: Leader Assure updated data use agreements are in place with partners (within 3 months of fellowship Finalize technical guidelines for transfer of chronic disease indicators from EHRs to public health (within 3 months of fellowship Initiate interface with 1 Community Health Center (within 3 months of fellowship Initiate interface with 3 additional Community Health Centers (within 6-9 months of fellowship Prepare Chronic Disease Snapshot for Community Health Centers (by end of fellowship). Role of Community Engagement Partners: The Council of Community Clinics (which represents the majority of Federally Qualified Health Centers in this region) is a member of Be There San Diego, which serves as the conduit to the clinical arena for the
3 Fellow. Public Health Services has previously worked on BMI surveillance with some of its sites and this relationship will be leveraged for additional opportunities for surveillance. Project 2 Title: Electronic Health Data Quality Improvement This project will develop guidelines to assess data quality and determine how to best utilize EHR data for the purposes of disease surveillance. Clinical data collected through EHRs will be critical for future surveillance efforts and methods to assess data quality will ensure that the resulting population estimates are accurate. The initial data collected through the Chronic Disease Surveillance project will be utilized for this quality improvement project. The identified data elements for Chronic Disease Surveillance include both diagnoses and the clinical and laboratory criteria related to those diagnoses. Standard diagnostic algorithms for hypertension, diabetes, and other chronic conditions of importance will be tested against patient diagnoses. This will provide a useful measure of the quality of care and help determine the extent of undiagnosed hypertension and diabetes. New York City and AcademyHealth s EDM group are leading a new Community of Practice to explore methods to improve the quality of electronic health data. The Secondary Supervisor has worked with colleagues from New York City and is a member of a new Community of Practice devoted to Modeling Electronic Health Data. The Fellow will join the Community of Practice and participate in calls and webinars to help inform the development of tools and methods for the County s surveillance system. Fellow s Project Role: Participant Develop guidelines for assessment of EHR data collected for chronic disease surveillance. Review data and initial analytic procedures (within 3 months of fellowship Develop outline of QI process (within 3 month of fellowship Test QI process on a single selected disease/condition and revise as needed (within 6 months of fellowship Finalize QI process and assess all diseases/conditions (within 9 months of fellowship Develop preliminary report on data quality for EHR-based chronic disease surveillance (by end of fellowship). Role of Community Engagement Partners: Dr. Suzanne Lindsay, the Executive Director of the Institute of Public Health (IPH), has a longstanding relationship with HHSA and has been a valued partner on several recent projects including the County s Communities Putting Prevention to Work grant. Though the Fellow will have involvement with the NYC/AcademyHealth Community of Practice, Dr. Lindsay and the IPH will assist in developing an Academic Advisory Group to serve as a local resource for EHR-based surveillance. The Academic Advisory Group will draw on local expertise in the development of methods, statistics, and tools from
4 the GSPH and the medical school at the University of California, San Diego to support the Electronic Health Data Quality Improvement project. Project 3 Title: Clinical Support and Blood Pressure Self-Monitoring The County has been awarded funding by CDC to implement coordinated strategies for State and Local Public Health Actions to Reduce Obesity, Diabetes, and Heart Disease and Stroke (1422). The goal of this new grant funding is to integrate evidence-based lifestyle change programs and other environmental strategies with health system interventions and community-clinical linkages to demonstrate the impact of coordinated efforts to improve community health. Through this work the County, with its clinical partners in Be There San Diego, will increase the use of self-measured blood pressure monitoring tied with clinical support. The initial step in this process will be to document the current efforts and readiness of health care partners to utilize self-measured blood pressure monitoring. This documentation, along with the results of Be There San Diego s CMMI pilot project utilizing wireless blood pressure monitors in a small group of Medicare/Medicaid recipients, will form the basis for development of recommendations to be included in a set of guidelines issued by a newly-formed Pharmacy Coalition regarding pharmacist involvement in clinical support for self-monitoring patients. The Fellow would participate in the documentation and the assessment of the current use of clinical support tools (with a particular focus on the utilization of decision support within EHRs) for blood pressure monitoring as well as work with the Pharmacy Coalition on the development of the new recommendations. This project will inform both local and national efforts to use a team-based care approach to manage chronic diseases and precursor conditions. Fellow s Project Role: Participant Improve the management of hypertension via patient activation by provision of pharmacist services via a multidisciplinary team approach in the clinical environment, amplified by involvement of community pharmacists. Understand the synergy of the multiple grants in San Diego focusing on improvement in improvement in hypertension management (within 1 month of fellowship Determine status of Be There San Diego's CMMI wireless blood pressure monitoring project related to pharmacist involvement via the Pharmacy Coalition (within 3 months of fellowship Determine assessment process for ascertainment of effectiveness, spread, etc., of selfmeasured blood pressure monitoring via CMMI and 1422 grants, with a particular focus on information captured and utilized within EHRs (within 6 months of fellowship Implement assessment process and write final report documenting lessons learned and recommended next steps (by end of fellowship).
5 Role of Community Engagement Partners: The Fellow would work with the Executive Director of Be There San Diego to support this project. The Be There Initiative has received substantial grant funding in recent months and is working to implement their CMMI grant as well as a CDC REACH grant to improve outcomes in a low-income community in southeast San Diego. And Be There San Diego will be the primary clinical interface for San Diego's 1422 grant, so there is inherent overlap among these activities.