Using EHRs to Improve Cascades in Primary Care Settings
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1 Using EHRs to Improve Cascades in Primary Care Settings Benjamin Young, MD PhD International Association of Providers of AIDS Care, Washington DC Josef Korbel School of International Studies, University of Denver
2 OVERVIEW Cascades Electronic Health Records and HIV Overview of the Alliance of Chicago HIV EHRs Preview of future HER plans
3 CASCADES
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7 CASCADES: ENGAGEMENT IN CARE
8 Engagement in HIV Care and Treatment :USA Gardner, et al., Clin Infect Dis 2011
9 Refocusing Engagement in Care and Treatment Those not:
10 ELECTRONIC HEALTH RECORDS AND HIV CARE
11 RECOMMENDATIONS FOR ADVANCING ENGAGEMENT IN CARE Develop integrated health informatics systems to collect real-time, actionable, patient-level surveilance of HIV testing and engagement in care activities Mugavero, Norton, Saag. Clin Infect Dis 201
12 Estimates of differences between EHR- and paperbased practices for 27,207 adults in 46 clinics. Composite standards: diabetes care 35.1% higher at EHR sites (P<0.001) Outcomes 15.2% higher at EHR sites (P<0.005) Use of EHRs may improve quality of care
13 Urban HIV outpt facility in Kampala, Uganda, implemented EMR Compared 2,383 visits (from 100 pts; paper) to 34,957 visits (from 10,920 pts, EMR) Decreased proportion of reporting errors from: OIs 66% to 2% ART toxicity 52% to 3.5% Reasons for ART interruption 83% to 12.5% Reasons for ART switch 94% to 0.9% EMR well accepted by providers
14 EMR AND HIV HEALTH CARE Meta-analysis of EMR-clinical decision support 12 studies (10 SSA, 2 Carribean) Improved ordering rates for CD4 Reductions in data errors, missed appointments Reduction in missed CD4 results and patient wait time Increased time spent in direct pt care Barriers: technical infrastructure, power cuts, connectivity, computer literacy High quality evaluations needed Oluch, et al., Int J Med Inform, 2012
15 PARTNERSHIPS
16 HISTORY AND MISSION OF COMMUNITY HEALTH CENTERS First funded by the Federal Government as part of the War on Poverty in the mid-1960s. Designed to provide accessible, affordable personal health care services for people living in medically underserved communities Mission encompasses quality, access, and responsiveness to particular needs of the community served. Typical services include primary care (Including Pediatrics, Internal Medicine, OB/GYN, and Family Practice), dental, behavioral health, nutrition, case management and health education.
17 HEALTH CENTERS WORKING INDEPENDENTLY Health Center Health Center Health Center Health Center Health Center Health Center Health Center
18 A LEARNING COMMUNITY Health Center Health Center Health Center Health Center Network Health Center Health Center Health Center
19 CHC HEALTH INFORMATION NETWORKS Consortia of multiple health centers supported by HRSA Collaborate, share, and/or integrate key functions core operations such as clinical, fiscal, IT, managed care, and administration
20 UNIQUE ROLE OF HEALTH CENTER NETWORKS Improve health outcomes and support quality care through: Development and adoption of electronic health record systems Track quality measurement Integrate clinical decision making and performance measures into a commercial EMR Research and evaluation
21 INTEGRATION OF HIV CARE INTO PRIMARY CARE SETTINGS: LESSONS LEARNED Enables health system to test more, initiate more ART, reduce loss-to-follow-up and achieve greater geographic coverage. Pfeiffer, et al., JAIDS, 2010 (Mozambique) May improve treatment outcomes by integrating evidence-based interventions for co-morbid mental health, substance use and neurocognitive disorders. Eustache, et al., PLOS Medicine, 2013
22 HIV MONITORING
23 MONITORING (CONTINUED)
24 EDUCATION & RETENTION
25 IMPLEMENTING PERFORMANCE IMPROVEMENT
26 POINT OF CARE REMINDER
27 RESULTS
28 SHOW PATIENT LIST
29 CONTACT PATIENTS Phone Letter SMS/Text
30 HCV MODULE DEVELOPMENT
31 PROJECT OVERVIEW Pilot Program to implement a shared Clinical Decision Support (CDS) Tool at clinics in two US cities (Chicago, IL and Huston, TX) that participate in the Alliance Network/Learning Community Focus of CDS was to support both screening and treatment of HCV Baseline data compiled related to screening and testing of HCV Capture data on use of CDS and impact of screening and treatment post CDS Implementation
32 FOCUS GROUP Members clinicians from CHCs with high incidence of people living with HCV Models of care integrated, vertical, referral Expense of treatment Need for policy and funding similar to RWCA Need for decision making tools to support HCV screening HCV treatment
33 CLINICAL CONTENT DEVELOPMENT PROCESS Partnership: IAPAC and The Alliance Key areas of clinical need identified and prioritized Subject Matter Experts (SMEs) are assigned to work with the Alliance Informatics Team to design and build the clinical templates Built templates are tested for usability and accuracy Approves content to put into use based on testing Alliance Informatics team creates necessary training material to support use
34 Test Sites Chicago and Houston
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38 CONTENT ROLLOUT Provided access to real-time and recorded webinar style trainings Issued a one page FAQ Offered on-site/live training Go-live was scheduled for March 1, 2013
39 PRELIMINARY RESULTS USE OF CDS BY SITES BY WEEK Teter, et al., DDW 2013
40 NEXT STEPS: HIV ENGAGEMENT IN CARE MODULE DEVELOPMENT
41 IMPROVING LINKAGE TO TESTING
42 Entry/Retention/Adherence Guidelines Entry and retention in HIV care Monitoring ART adherence Interventions to improve ART Adherence Adherence tools for patients Education and counseling interventions Health system and service delivery interventions Special populations Thompson MA, et al., Ann Int Med 2012; 156(11):
43 RECOMMENDATIONS: ENTRY INTO/RETENTION IN CARE Systematic monitoring of successful entry into HIV care is recommended for all individuals diagnosed with HIV (II A). Systematic monitoring of retention in HIV care is recommended for all patients (II A). Brief, strengths-based case management for individuals with a new HIV diagnosis is recommended (II B). Intensive outreach for individuals not engaged in medical care within 6 months of a new HIV diagnosis may be considered (III C). Use of peer or paraprofessional patient navigators may be considered (III C). May
44 Zuniga and Young, JIAPAC 2013
45 SUMMARY EHRs can improve health-related outcomes Development process should engage stakeholders at all levels EHR implementation can facilitate CDS use EHR-CDS modules in development to incorporate normative guidance for engagement in HIV care
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48 ACKNOWLEDGMENTS Alliance Shannon Pohl Andrew Hamilton IAPAC Vincent Congiu Imane Sidibé José Zuniga
49 ACKNOWLEDGMENTS Alliance Shannon Pohl Andrew Hamilton IAPAC Vincent Congiu Imane Sidibé José Zuniga
50 Questions? Benjamin Young
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