Albuquerque Area Beacon Community Project

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2 Project Abstract Project Title: Albuquerque Area Beacon Community Service area : Bernalillo County: 870XX and 871XX, Sandoval County: 870XX, 871XX, 87544, Torrance County: 870XX and 88321, Valencia County: 870XX Applicant Name: New Mexico Department of Health Address: 1190 St. Francis Dr. N3150 Santa Fe, NM Contact Name: Robert Mayer Contact Phone Numbers (Voice, Fax): Voice Fax Address: Robert.Mayer@state.nm.us Web Site Address, if applicable: The Albuquerque Area Beacon Community ABC) project is a community-wide effort focused on the Albuquerque Metropolitan Statistical Area to enhance and leverage sophisticated health information technology tools in hospitals and physician practices to accomplish transformational improvements in key quality, cost-efficiency, and population health measures relative to specific common conditions. Supported by funding from the Office of the National Coordinator for HIT (DHHS), the Albuquerque program is led by the New Mexico Department of Health and a consortium of four partner organizations (LCF Research, University of New Mexico, New Mexico Medical Review Association, and New Mexico Primary Care Association). The goals include: increasing community-wide deployment of ambulatory EHRs from 47% to 85% over the three-year project period; continued implementation of the health information exchange (HIE) network with a goal of 90% adoption by area practices and hospitals; linking telehealth providers to EHR and HIE deployment; and achieving significant improvements in 9 clinical measures associated with common conditions that are designed to improve quality, cost-efficiency, and population health (e.g.,, increase pneumonia vaccination rate for age 65+, reduce unnecessary lab test and imaging, increase breast cancer screening rates). These clinical measures were chosen for their measurement feasibility, well-developed evidence, and potential for improvement without clinical encounters. Collection and analysis of race, ethnicity, and language measures will be an essential component of the initiative, given the substantial ethnic and socioeconomic diversity of the Albuquerque area population. The strategy for accomplishing the objectives is to have the ABC consortium work with and mobilize medical informaticists and data analysts in the local practices and hospitals to design data extraction and clinical decision support tools and assist in the design and evaluation of interventions. Governance and oversight will be provided by an Executive Steering Committee led by the State HIT Coordinator in the NM Department of Health that will include a representative of each of the consortium partners. The broadly representative 35-member Board of Directors of LCF Research (the state-designated HIE and primary subcontractor to the NM Department of Health for Beacon) will serve as the Stakeholder Steering Committee. The project will be closely affiliated with the local Aligning Forces for Quality program operated by NMMRA, one of the Beacon consortium members, and with the state s proposed HIT Regional Extension Center (also led by LCF), to take advantage of the synergy among the three programs. Veterans Affairs and the Indian Health Service will participate in order to leverage their HIT resources for more coordinated, efficient care. It is anticipated that the desired outcomes will largely be accomplished, and the positive outcomes will be the foundation for the refinement of a sustainability plan based on engaging payers and providers in the funding and continuation of the Beacon program and its key HIE and quality/efficiency/public health improvement components.

3 Introduction: Under New Mexico Department of Health leadership, four Albuquerque organizations will come together to create the Albuquerque Area Beacon Community (ABC) to apply their complementary skills and extensive relevant experience to achieve a striking HIT-leveraged transformation of health care quality and efficiency in the community. The Albuquerque area medical community consists predominantly of large hospital systems and group medical practices in which the ambulatory EHR adoption rate is 47%. In addition to high EHR use, our ethnically diverse community is an excellent laboratory for a successful Beacon program which will build on three significant community-wide health IT/quality initiatives: (1) the New Mexico Health Information Collaborative, our state s designated Health Information Exchange and one of the nine original Nationwide Health Information Network participants, (2) Aligning Forces for Quality, a Robert Wood Johnson Foundation program awarded to only 15 U.S. communities, and (3) a soon-to-befunded proposal for the New Mexico HIT Regional Extension Center from ONC which is led by a similar consortium to that leading the Beacon effort. We propose building the Albuquerque Area Beacon Community upon this strong foundation to focus on its primary goals of enhancing HIE capability and adoption, expanding EHR deployment, and supporting medical informatics teams within practices, so that individual EHR and joint HIE resources are collectively used to improve the quality and cost-efficiency of managing specific common clinical and population health problems. ABC will include Veterans Affairs and Indian Health Service facilities because they provide substantial community care and share the need to leverage their HIT resources for more coordinated and efficient medical care. A. Current State and Gap Analysis of EHR Adoption and Meaningful Use To estimate our community s baseline EHR adoption rate, our team assessed EHR use within the large delivery organizations and small provider groups through personal contacts, vendor contacts or organizations which assist practitioners in EHR adoption. We determined that 47% (1560) of our service area s 3340 physicians, physician assistants and nurse practitioners are utilizing an EHR for outpatient 1

4 longitudinal documentation, electronic receipt of laboratory data, and electronic medication management. We expect that an additional 487 clinicians will adopt similar ambulatory EHR functions in 2010, for a total of 2047 using outpatient EHRs. If our consortium members are awarded the HIT Regional Extension Center funds (which we anticipate in February, 2010), we will be able to further shrink the remaining ambulatory EHR adoption gap of 1093 providers. Determining the hospital-based clinician denominator is more challenging. Based on the numbers of hospital-based and hospital-employed providers provided to us by the ABC area hospital systems, we estimate that 69% (1518) of the 2190 hospital-based practitioners use HIT for computerized physician order entry (CPOE), clinical documentation, and medication management. Lovelace Health System, the second largest hospital system in the Albuquerque Area Beacon Community jurisdiction, will complete EHR adoption during 2011, bringing the inpatient adoption rate to at least 69% of all ABC area inpatient clinicians. Determine number of providers targeted for direct assistance, and the proportion this represents of the total number of providers. We propose to provide direct assistance to promote advanced HIT use to 2047 current and expected EHR users between now and Of the 1093 clinicians who comprise the ambulatory EHR adoption gap, the ABC consortium proposes to provide direct assistance to 800, resulting in ABC benefits to 85% of our service area clinicians. Identification of the geographical area that is served by the proposed Beacon Community Program: Geographic Border: The consortium is proposing the four-county Albuquerque Metropolitan Service Area (MSA) as the geographic area for the Beacon Community Program. The four MSA counties are Valencia, Torrance, Sandoval, and Bernalillo. We are proposing the Albuquerque MSA because this area exceeds the minimum requirements of EHR adoption (more than 45% of physicians have adopted EHR systems), has a large population base, has a rural/urban mix, aligns with AF4Q and other quality 2

5 improvement programs, includes a significant level of minority/underserved populations, and is the complementary urban core to support the more rural HIT Regional Extension Center focus. Characteristics of Healthcare Community. Albuquerque is the medical hub for the state of New Mexico. Although Albuquerque residents comprise only 26% of the state s nearly 2,000,000 citizens, the Albuquerque hospitals account for 45% of all hospital discharges for the entire state. In addition, 50% of the New Mexico physicians work in Albuquerque, and 53% of New Mexico specialists are based there. Geographically, Albuquerque is in the center of the state and is located at the crossroads of the major transportation arterials crossing New Mexico. The Albuquerque MSA includes seven hospitals, 13 New Mexico Department of Health clinics, 17 Federally Qualified Health Centers, 18 University of New Mexico clinics, seven Indian Health Service clinics, and four large physician practices (ABQ Health Partners, Presbyterian Medical Group, UNM, Veterans Administration). Determine number of uninsured, underinsured, medically underserved, and minority individuals as a proportion of the service area s total population The four counties of the Albuquerque MSA reflect the diverse demographic composition of New Mexico s population. The area is home to 875,000 people constituting approximately 42% of the state s total population. 1 The 2008 population estimates for the Albuquerque MSA include 86% White (both Hispanic and non-hispanic), 4% Black or African-American, 6% American Indian, 2% Asian, and 2% Other. Of the 86% White population, 45% are Hispanic and 41% are White non-hispanic. In 2007, the Pew Hispanic Center estimates that New Mexico ranks first in the nation for Hispanics as percent of the total state population. Of the New Mexico Hispanic population, 83% are native born, the fourth highest rate in the nation. The Albuquerque MSA includes five American Indian pueblos (Sandia, Isleta, Zia, Jemez, and Santa Ana), and the 2000 census reports that Albuquerque has the 7 th largest urban Indian population in the nation. 1 BBER-UNM: BBER population estimates

6 According to 2008 statistics published by the New Mexico Health Policy Commission, 21.9% of the New Mexico population is uninsured, 2 which is significantly higher than the national uninsured rate of 15.4%. 3 The Current Population Survey report estimates the New Mexico uninsured rate at 23%, placing it second behind Texas (24.9%). In addition, the uninsured rates in New Mexico are 23% for Hispanics, 28% for American Indians, and 11% for non-hispanic Whites. The uninsured rate for the Albuquerque MSA approximately mirrors the uninsured rate for New Mexico. New Mexico s Medicaid program provides health insurance coverage to approximately 24% of the state s population. 4 However, it is estimated that at least 11% of New Mexico s children remain uninsured. Of those children who are uninsured 82 % are eligible for Medicaid and have not been enrolled. 5 It is also estimated that 29% of New Mexicans with insurance are underinsured, 6 meaning that they have health insurance, but do not have adequate coverage for the cost of prescription drugs, medical visits, or medical procedures. 7 Applying this rate (29%) to Albuquerque MSA population of 875,000 residents indicates that an estimated 253,750 underinsured residents reside in the Albuquerque MSA. In 2008, the New Mexico Human Services Department reported that New Mexico had the fourth highest rate of poverty in the U.S., behind Mississippi, the District of Columbia, and Louisiana. 8 New Mexico s high rate of poverty underpins all aspects of healthcare. Within the Albuquerque MSA, rural Torrance and Valencia Counties have the highest rates of families living in poverty, with a striking 15.2% and 13.5%, respectfully. 9 2 New Mexico Health Policy Commission 2008 Health Insurance Community Rating and Guaranteed Issue and Briefing Paper Current Population Survey - Estimates Revised CPS ASEC Health Insurance Data, May 4, NM Human Services Department, Medical Assistance Division New Mexico Medicaid Facts, July Common Cause New Mexico. The Role of the Health Insurance Industry in New Mexico State Politics. February, Consumer Reports National Research Center Health Care Survey 8 NM HSD, Sec report to the Governor, Slightly More New Mexicans Living in Poverty in US Census, New Mexico Quick Facts,

7 In the United States, nearly 12% of people live in a "medically underserved area" ("MUA"), an area with reduced access to primary care physicians. New Mexico is ranked 50 th out of 50 states and the District of Columbia, with 27.6% of its population living in a full or partial MUA. Thirty two out of New Mexico s 33 counties are either full or partial MUAs. 10 Of those New Mexicans living in a designated MUA, 36% are uninsured. 11 Overview of Ethnicity and Underserved Characteristics of the Albuquerque MSA Characteristics Bernalillo Sandoval Torrance Valencia New Mexico Hispanic 45.8% 33.0% 37.7% 55.8% 44.9% American Indian 5.1% 13.5% 2.6% 4.0% 9.7% Uninsured % 24.4% 29.1% 29.3% 29.1% Uninsured under 19 yrs of age 15.2% 15.8% 19.8% 18.5% 17.0% Underinsured 29.0% Medically under served12 < Families living in poverty % 8.7% 15.2% 13.5% 13.7% Determine number of Federally Qualified Health Centers (FQHC) and public non-profit Critical Access Hospitals (CAH) in the service area The New Mexico Primary Care Association (NMPCA), one of the ABC consortium members, focuses on the needs of the uninsured and underserved populations in the Albuquerque MSA. NMPCA's Federally Qualified Health Center (FQHC) members in the service area are: First Choice Community Healthcare, Health Care for the Homeless, First Nations, and Presbyterian Medical Services as well as El 10 Women s Access to Health Care Services ( Areas.aspx) 11 Department of Health Policy D20-3D2A570F2CF3F8B0.pdf 12 MUA designation by HRSA A number > 62.0 is not considered a MUA. 13 US Census, American Community Survey

8 Pueblo Health Services, a FQHC Look-alike. Collectively, these five FQHCs have 40 providers at 18 primary care practices. They provide health services to 77,718 patients who are indigent, uninsured, minorities, and/or homeless within the Albuquerque MSA. An overview of the four FQHC's and the one FQHC Look-alike: * First Nations provides services to Albuquerque's urban Indian and other minority populations. In 2008, First Nations had 8703 encounters, of which, 60% were American Indian and 31% were Hispanic. * First Choice Community Healthcare provides services at eight locations in Bernalillo and Valencia Counties. One of the eight sites is a school -based health clinic in Albuquerque's South Valley. In 2008, First Choice had 133,500 encounters, of which, 71% of the patients were Hispanic and 31% were children age 19 and under. * Presbyterian Medical Services provides services in seven locations in Sandoval and Torrance Counties. In 2008, Presbyterian Medical Services had 37,710 encounters, of which, 39% of the patients were Hispanic, 14% were American Indian, and 31% were children age 19 and under. * Albuquerque Health Care for the Homeless is the only health care organization in Central New Mexico dedicated exclusively to providing health care services to homeless people, providing critical services to over 7,500 men, women and children every year. * El Pueblo Health Services in the town of Bernalillo in Sandoval County is an FQHC-Look alike. In 2008, they had 20,241 encounters. They are not required to report demographics by age and ethnicity. Number of FQHC and public and non-profit Critical Access Hospitals (CAH) in the service area There are eight hospitals within the service area including the federally funded VA hospital and the not-for-profit University of New Mexico Hospital. There are no Critical Access Hospitals (CAHs) in the proposed Albuquerque MSA. There are, however, two acute care medical centers that serve as support hospitals for CAHs outside of the MSA. Presbyterian Medical Center is the support hospital for Socorro 6

9 General Hospital and the University of New Mexico Hospital is the support hospital for Sierra Vista Hospital. Beacon HIE connection with these support hospitals will improve the communication and patient care for the CAHs they support. Describe partnership or collaboration with a community college or other institution of higher education offering a certificate or associates degree program(s) in health information technology or related field (please specify). The partnership/cooperation with the University of New Mexico Health Sciences Center (UNMHSC) and its hospital (UNMH) has several dimensions, including education on biomedical informatics, the Center for Telehealth and Cybermedicine Research ( an ABC consortium member, the implementation of computer-based physician order entry, a pilot to support Medical Homes, participation in Aligning Forces for Quality (AF4Q), agreement to participate in the state HIE network, and other dimensions relevant to the Beacon Community proposal, such as providing a secure gateway to UNM s EHR and associated data. Although UNM does not offer a certificate or associate degree program in HIT, the UNM Health Sciences Library and Informatics Center (HSLIC) has had a biomedical informatics (BMI) training program (a research fellowship) since The purpose of the fellowship is to take those individuals with terminal degrees in the biosciences (e.g., MD, PhD, PharmD, PT) and train them to be independently fundable biomedical informatics investigators and academicians who can perform much needed research in BMI and help meet the shortage of educators in the BMI area. The UNMHSC also offers a Masters of Science in Clinical Research that contains a significant biomedical informatics component in its Clinical and Translational Science Center (CTSC). The UNM CTSC has a biomedical informatics core resource that is working on developing tools to link UNMH EHR data with data in the TriCore (the largest reference laboratory in New Mexico) database. These databases are currently available to UNM investigators for research. 7

10 UNMH has an enterprise-wide electronic health record with computerized physician order entry. UNMH has been named one of the 100 Most-Wired Hospitals and Health Systems in the U.S. by the American Hospital Association (AHA) for the sixth consecutive year, and seven years total. In the 11-year history of the AHA's Most-Wired Program, only nine U.S. organizations have made the most-wired list seven times. UNM Hospital, the state's only Level I Trauma Center, is the sole New Mexico hospital on this year's list. The hospital has a presence within or in close proximity to the service area of a VA hospital, DoD medical facility, IHS, and/or other tribal health facilities as well as other healthcare organizations to provide and extend existing infrastructure to support the secure electronic exchange of health information with labs, pharmacies, diagnostic centers, and other entities targeted for collaboration in the MSA.. Describe proximity to the service area of a VA hospital, DOD medical facility, IHS or other Tribal health facility. The federal government plays a prominent role in New Mexico healthcare through such programs as the Department of Defense, Veterans Affairs, and Indian Health Service. Because of New Mexico's location and participation in federal military activities, its population includes a significant number of veterans, active duty personnel, and military retirees. New Mexico is home to many Native American tribes and pueblos and their health care facilities. The only Veterans Affairs Hospital in New Mexico is in Albuquerque. The major military base in the state is also in Albuquerque and shares a unique relationship with the Veterans Affairs Hospital by sharing and co-locating facilities and support activities. Albuquerque is also the residence of the Indian Health Service Area Office, which coordinates healthcare activities for the western region of the state as well as information technology activities for the entire IHS. Specify and briefly describe presence of organization(s) to provide for and/or extent of existing infrastructure(s) providing the secure electronic exchange of health information within the geographic service area. The Albuquerque MSA consists of 3340 physicians (with a large concentration of them across three large healthcare systems), several medium size physician practices, and various small practices. The 8

11 three large systems, Presbyterian Healthcare Services, Lovelace Health System, and University of New Mexico, are either currently connected to the New Mexico Health Information Collaborative (NMHIC) or scheduled for connection in the first half of Part of the plan for our Beacon program will be to assist as many of the medium and small size physician practices as practical by helping them deploy (or use existing) EHR systems to allow their integration with NMHIC, thus facilitating care coordination, meaningful use, and achievement of our Beacon clinical goals. NMHIC has been designated by the Governor of New Mexico as the state-designated entity (SDE) for health information exchange. NMHIC has also been designated by the NM Department Health as their agent for electronic reporting of reportable lab and emergency department conditions. LCF Research owns and operates NMHIC, and its Board of Directors contains senior leadership representatives from State Government (NM Department of Health and NM Medical Assistance Division), the large healthcare delivery systems, major healthcare payers, private industry, and all members of the Beacon consortium. In addition to NMHIC and HIE infrastructure, the ABC consortium will also be building telehealth capacity through its consortium member, the University of New Mexico Center for Telehealth (CfTH) and Cybermedicine Research. CfTH assists health programs in integrating telehealth into their initiatives, providing technical, network, business, and operational planning and design. Over the past 14 years, the Center has been a leader in the expansion of a statewide telehealth network of networks and development of a vast array of telehealth programs addressing the health needs of communities throughout the state. There are over 150 telehealth sites in more than 50 communities in New Mexico representing numerous health care provider organizations. The CfTH was recognized by the American Telemedicine Association (ATA) and given the President s Institutional Award for its efforts in advancing telehealth locally, nationally, and internationally. As an example of its statewide telehealth role, the CfTH (although receiving no federal support for project administration) is managing a large project, funded by the Federal Communications Commission (FCC) Rural Health Care Pilot Program, to coordinate the network engineering design, 9

12 modeling, build-out, operations and evaluation of an enhanced collaborative telemedicine network called the Southwest Telehealth Access Grid (SWTAG), serving New Mexico, Arizona and the Southwest IHS Area Offices. The Center has now aligned itself organizationally and strategically with the UNMHSC Office for Community Health, to address community health needs throughout New Mexico and to extend health services, education, training and community-based participatory research through the use of telehealth. Describe labs, pharmacies, diagnostic centers, and other entities targeted for collaboration. The Beacon Community proposal funding would allow the ABC consortium to work with over 150 health-related organizations, including laboratories (28), pharmacies (111 plus 6 pharmacy systems), and diagnostic centers (23 imaging, x- ray, and mammography), and the UNM Cancer Center (see attached listing) to tie these ancillary/diagnostic centers together to improve the quality of healthcare delivery in the MSA. Of note, the Albuquerque Area Beacon Community (ABC) partners are currently working with all the pharmacies and many of the other diagnostic/ancillary services listed. B. Goals and Objectives Provide a detailed description of the specific and measurable health IT infrastructure and exchange, cost-efficiency, quality and population health improvement goal(s) of the proposed services (must identify at least one of each goal) The communitywide program goals were selected because they reflect the shared vision of consortium members and participating healthcare organizations and practices, address the health care needs of minority and underserved populations, meet health plan, national, and local performance improvement goals, and support meaningful use criteria. In addition, information about their performance is contained in approachable electronic data and reflects the strengths of the HIT community. Our Beacon program will supply practitioners with better information technology tools to improve care by (1) mobilizing health data within and across the community and (2) harnessing health information technology to better apply that information for care. Enhancing existing HIE and EHR technology and expanding the footprint of these technologies will be our primary short-term goal. Our long-term goal is to integrate HIT seamlessly 10

13 into the care process to achieve transformational improvements in health care quality, cost-efficiency, public health measure and in the reduction of health disparities for disadvantaged populations. The clinical goals were selected to address quality, cost-effectiveness, and public health aspects of the Beacon requirements and build upon three existing community programs that unite our medical community: (1) health information exchange, (2) Aligning Forces for Quality (AF4Q), and (3) health information technology regional extension center. The table below lists these goals, briefly described process and outcome measures, the Beacon priority areas and relevant meaningful use objectives articulated in the Proposed Rule at the time of this proposal submission. Since each goal can impact more than one Beacon priority, each goal s primary Beacon priority is listed first in that column. Goals are listed in two general sections: those relating to ambulatory (A1-A7) or hospital EHR use (H1). Footnotes reference quality guidelines and organizations. Strategies and operational characteristics of implementing these goals will be discussed below this table. Clinical Goal Population Focus A1. Improve adult vaccination rates for the elderly and medically indicated. Process Measure 1. Track influenza, pneumonia, and zoster vaccine delivery. 2. Transmit immunization information via NMHIC HIE to state immunization registry. 3. Identify racial/ethnic differences in measurement and immunization delivery over time. 4. Incorporate pharmacy delivered immunizations into EHR data via HIE. Outcome Measure 1. Reduce rates of ED, hospital, and urgent care encounters for pneumonia, influenza, and zoster. 2. Examine claims cost consequences over time. Beacon Priority Population Health Prev. Health Services - immunizations PH Surveillance real time monitoring for influenza and pneumonia morbidity Patient Health Cost efficiency preventable ED visits and hospitalization Population Meaningful Use Objectives Generate lists of patients by specific conditions, report quality measures, and submit electronic data to immunization registries. A2. Improve bi- 1. Provide surveillance Reconcile Generate lists 11

14 Clinical Goal direction exchange of childhood vaccination information between the EHR community and the NM State Immunization Information System registry through HIE. 4 A3. Improve electronic description of the smoking population via EHR HIE participation 1,3,4,5 Cost Efficiency Focus A4. Reduce laboratory and image test ordering variation by describing existing variation across the entire community of participating practitioners. 1. A5. Facilitate drug therapy cessation for several, common high cost or risky drugcondition therapies where treatment Process Measure and targeting of Done by One 2. Improve completeness and transportability of immunization records across Beacon community EHRs via HIE and public health interoperable exchange 1. Describe smoking data collection approaches across practices. 2. Compare completion of EHR data 1. Describe variation of routine and expensive tests 2. Correlate variation with other variables within EHR record. 1. Identify and enumerate therapy epidemiology and associated costs for community. 2. Assess guideline measurement and adherence following Outcome Measure immunization data across different sources of rates for infants and young children Describe variation data across different populations and practices 1. Reduce variation 2. Describe high cost testing frequencies. 1. Reduce cost of drug use. 2. Reduce hospital admission or ED episodes related to medication Beacon Priority Health Prev. Health Services - immunizations PH Surveillance real time monitoring for influenza and pneumonia morbidity Patient Health Cost efficiency - preventable ED visits and hospitalization Population Health Smoking epidemiology Health Disparities minorities and underserved populations Patient Health Cost Efficiency encourage reduced use and variation Patient Health Cost-efficiency avoiding inappropriate services, and encouraging cost effective Meaningful Use Objectives of patients by specific conditions, report quality measures, and submit electronic data to immunization registries. Record smoking status for patients >=13 years old and report quality measures. Receive laboratory data electronically. Maintain active medication list, generate lists of patients by specific conditions, and report quality 12

15 Clinical Goal cessation is the appropriate action. 4,5 Quality Focus A6. Decrease cholesterol levels in patients with known CAD and diabetes. 1,2,3,4 A7. Improve appropriate Breast and Cervical cancer screening in disadvantaged populations. 1,2,3,4,5 Process Measure identification of patients and providing their prescribers information and action plans for medication alteration 1. Describe LDL cholesterol levels across a community 2. Create a registry of patients with known disease across multiple delivery systems 3. Develop community shared, non-visit or telehealth patient education and promotion efforts for medication adherence 4. Monitor medication possession ratios 1. Compare screening rates across insurance types and race/ethnicity categories over time. 2. Develop community shared, non-visit or telehealth patient education and promotion Outcome Measure therapy adverse events 1. Reduced CV events (cardiac, stroke and PAD). 2. Possible participation in the national CV surveillance research sites for comparative outcomes. 3. Examine formulary adherence over time. 1. Monitor highrisk cervical lesions rates. 2. Monitor completion of abnormal pap/mammogram follow up care Beacon Priority prescribing Quality - Adverse drug events Population Health Health Disparitiesexamine variation in prescribing status and change across demographic groups Patient Health Quality lipid control Cost Efficiencies hospitalization, preventable ED visits Population Health Health Disparities minority and under- served populations PH Surveillance - participation in national surveillance Patient Health Quality prevention improvement Cost Efficiencies decrease redundant services Meaningful Use Objectives measures. Report quality measures, generate lists of patients by specific conditions. Report quality measures, generate lists of patients by specific conditions. 13

16 Clinical Goal A8. Improve asthma treatment adherence and smoking exposure (i.e. asthma trigger). 2,3,4 Process Measure efforts for screening adherence. 3. Enumerate the instances where linking sources of imaging data through HIE improves record completeness 1. Create community registry across multiple delivery systems 2. Assess medication possession ratios 3. Generate action lists for medical groups where patients lack chronic medication prescriptions or lapses in refills of chronic medication prescriptions 4. Record smoking status in EHR Hospital Oriented Goal H1. Improve 1. Delivery of electronic discharge discharge communication summaries/plans between hospitals 2. Decline in requests for and outpatient records after discharge clinicians 3. Measure HIE and responsible for Telehealth use care handoffs and coordination. 1,5 1 Meaningful Use Stage 1 Outcome Measure Reduce rates of ED, hospital and urgent care encounters for asthma treatment over time. Reduced: 1. Readmissions 2. # of follow up visits Beacon Priority Population Health Prevention recommended CA screening Health Disparities minority and/or underserved pop. Patient Health Quality - proper medication therapy Cost-efficiency Preventable ED and hospitalizations Population Health Tobacco Control Health Disparities minority and underserved and telehealth PH Surveillance asthma registry or asthma morbidity Patient Health A. cost-efficiency preventable ED visits or inappropriate care, generic prescribing B. Quality improve patient quality of life Meaningful Use Objectives Record smoking status for patients >=13 years old and report quality measures. Capability to exchange key clinical information and provide summary care records. 14

17 2 Albuquerque Coalition for Healthcare Quality, an Aligning Forces for Quality initiative, Proposed Reporting Algorithm 3 Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) 2010 Measures List HEDIS Measures 5 Measures in related contracts held by ABC consortium members Include baseline (or best estimate) for the selected cost-efficiency and health outcome(s) goals in the community and the degree of improvement hoped to accomplish In the following table each clinical goal is listed, followed by an estimate of current measurement of that goal in our service area, and the source of that estimate. In the last column we have projected achievable change after 30 months of Beacon activity. These projections reflect our judgments about local community capacity to use Beacon resources and accomplish change. Additional detail regarding pre-abc rates is provided below the table. Goal Pre ABC Pre Estimate Source Post ABC A1 Pneumococcal vaccine for those age 65 and above 60% CDC 80% A1 Shingles vaccine for those age 60 and above 7% CDC 14% A2 Process bi-directional childhood immunization exchange 0 no data available 10,000 children A3 Document smoking status in EHR nil no data available 300,000 patients A4 Reduce duplicate laboratory tests 936,000 local database study 47,000 fewer duplicates A4 Reduce duplicate imaging tests 98,142 local database study 4,900 fewer duplicates A5 Reduce prolonged clopidogrel therapy 59% local database study 40% A5 Reduce concurrent omeprazole/clopidogrel therapy 12% local database study 6% A5 Reduce Gyburide use in diabetic patients with diminished renal function 5% local database study 2.5% A6 Reduce LDL cholesterol levels in patients with known CAD and DM below 27% local and national data 10% 100 A7 Improve breast cancer screening 46% local Medicaid performance 57% A7 Improve cervical cancer screening 67% local Medicaid performance 73% A8 Increase chronic medication therapy in asthma 87% local Medicaid performance 90% A8 Document smoking status of parents of asthmatic children unknown no data available 200 children 15

18 H1 Improve admission/discharge notification to primary care doctors via HIE H1 Increase availability or delivery of discharge summaries via HIE 0 function unavailable 0 function unavailable 90% of physicians 90% of physicians Regarding the Pre-ABC measures, the first two are based on CDC data at For the A2 goal, no bi-directional immunization exchange exists today, so baseline performance is zero. Although A3 information is collected in most practices today, little of it is stored in standard and retrievable electronic forms, except for the VA. We expect conversion to electronic representation of the information to occur swiftly as EHR systems adopt more standard approaches. For A4 a local claims database study provides an estimate of possible redundant laboratory testing: 101,363 individuals had a claim paid for at least one outpatient laboratory test, with 786,433 separate lab tests performed (7.8/person; a range of 1 to 386/person). Extrapolating this to the ABC area estimates the performance of 4.7 million tests and claims totaling $11.8 million ($116.99/person, $15.08/procedure). In the study database population, the same laboratory test was repeated within 30 days 158,167 times. This extrapolates to 936,000 duplicates and $1.4 million (12% of all claims paid for laboratory tests) in the ABC service area. Assuming that 95% of these duplicate orders were clinically warranted, there is still a potential savings in laboratory claims paid of over $700,000 for the proposed service area over a one-year period. A similar estimate of possible redundant imaging testing was derived from the same database. This studied patient care population received 286,009 procedures (3.6/person), and 98,142 were associated with a duplicate order within 30 days (total claims paid--$5.8 million). We estimate that 5% of these are avoidable duplicates, which are associated with $290,000 in claims. Extrapolating to our ABC 16

19 population, a total of 1.8 million procedures are estimated annually, resulting in $117 million in claims and potentially avoidable duplicates of $2 million annually. For A5 we chose two specific drug condition combinations which have significant cost and quality impact. The following describes our estimate based on 2009 data from a local source. Clopidogrel (Plavix) therapy is expensive ($156 for 30 days) and associated with heightened risk of internal bleeding. Typical therapy lasts 12 months, with occasional patients needing prolonged therapy. Although most patients therapy should be discontinued at 24 months, this decision is frequently missed because key information about cardiology interventions and indications is unavailable to the clinician, who must renew or discontinue the medication. As a result, expensive and risky therapy is continued beyond current indications. Furthermore, patients who take concurrent omeprazole nullify the benefit of clopidogrel. In a local study, 59% (898) of 1520 patients prescribed clopidogrel were receiving the medication for longer than 24 months, and 12% (190/1520) were prescribed concurrent omeprazole. Since patients receive their specialty and primary care across the whole community, it is not surprising that this unnecessary expensive and high-risk situation often occurs. ABC-supported HIE and medical informatics capacity can assist clinicians to address this therapy conflict. An identical process can be used to address the risk of hypoglycemia imposed upon diabetic patients who are prescribed Glyburide even though they have compromised renal function (defined as a serum creatinine <1.5 or egfr<50). The local study found 5% of patients (90/1933) who face this unnecessary risk. For A6, substantial literature documents insufficient cholesterol lowering medication therapy in routine medical practice. One recent study indicates only 50% achievement of cholesterol goals (Kennedy AG - Diabetes Care - 01-MAY-2005; 28(5): ). Using 2009 local data for 8067 patients with known coronary artery disease, diabetes, stroke or peripheral arterial disease, 311/8067 did not have an LDL measure within 2 years of initiating statin therapy, and 846/8067 did not have a measure during the 17

20 previous 12 months of therapy. Of the 8067 patients, 2233 (28%) did not have their most recent LDL <100, and many current guidelines recommend more rigorous LDL targets under 70. For A7 and A8 local Medicaid performance data was used from one health plan participating in ABC, and projected performance is based on achieving Medicaid benchmarks. The smoking component of A8 will depend on informatics matching of parent/child relationships and data acquired as part of A3. For H1, we know that the three private hospital systems involved in ABC account for 90,000 acute hospital discharges annually and for 45% of all acute hospital discharges for the entire state of New Mexico; the VA adds another 5000 discharges. Currently, the HIE is not capable of electronically notifying outpatient, primary care physicians when their patients are admitted or discharged from the hospital or delivering to them an electronic hospital discharge summary via HIE portal or HIE-to-EHR transmission. The ABC program will add that capacity to our HIE. VA participation in this activity will be determined by national VA leaders and their commitment to making this function available via NHIN, in which NMHIC already participates. B. Proposed Strategy Describe previous success and/or advanced core competencies in Health Information Technology and Exchange Infrastructure, Practice Redesign and Care Coordination, or Evaluation, Performance Monitoring and Feedback Our Beacon qualifications include advanced EHR adoption (47% of ABC area practitioners detailed previously, relevant competencies of our four consortium members and NMDOH, experience in practice redesign, experience in HIT-based practice improvement, and nationally recognized, exemplary health information exchange development. New Mexico Health Information Collaborative (NMHIC) is our HIE organization, which is a critical foundation element of this proposal (see description below).. 18

21 New Mexico Health Information Collaborative is the State-Designated Health Information Exchange (HIE) for New Mexico and the Albuquerque metropolitan statistical area. It is operated by LCF Research. NMHIC successes and core-competencies include: Broad community support. From September 2004 through September 2007 NMHIC received approximately $500,000 per year from AHRQ and approximately $500,000 in matching funds from 35 major stakeholders in the New Mexico community, including providers, payers, state agencies, employers, professional associations, and consumer organizations. Representatives from 33 of these stakeholders participated in the NMHIC Steering Committee from 2004 through 2008, and 35 serve as voting members of the new LCF Research Board of Directors. Comprehensive strategic and operational plans. NMHIC worked closely with its stakeholders during 2008 and 2009 to develop a comprehensive business plan and State HIE plan for ONC. ONC has indicated that New Mexico is one of only nine states to submit a comprehensive statewide HIE plan by the end of 2009 and one of the few states who will proceed directly to HIE implementation funding. Advanced technical infrastructure. NMHIC s technology partner, MedPlus, has vigorously supported NMHIC advancement with a federated architecture model, an advanced statewide Master Person Index, a record locator service, web-portal and edge servers, and interface engine capabilities. NMHIC demonstrated its HIE network capabilities in 2008 when it participated in the live Nationwide Health Information Network (NHIN) Trial Implementations demonstrations with HIEs in New York, Long Beach, California and with the Veterans Health Administration. The management and professional staff of NMHIC were active participants in all NHIN Committees and Workgroups during this time. Privacy and security protections. NMHIC played a leadership role in the New Mexico Health Information Security and Privacy Collaborative (HISPC) during 2006 and 2007 and in the development and passage of a new NM state law addressing EHR and HIE use and related privacy issues.. 19

22 Additional HIT infrastructure competencies. Network competencies include (1) HealthXnet, a network that supports administrative transactions, (2) New Mexico Prescription Improvement Coalition which supports e-prescribing, and (3) the University of New Mexico s Center for Telehealth which provides leadership and incubation for telehealth initiatives. Practice redesign competency. Coalition members NMMRA and NMPCA have significant experience in office redesign and technical assistance relative to EHR adoption. Their staff understands patient flow, point of care documentation, in-office communication, chart abstraction, and document management aspects of EHR deployment. This experience has been gained by assisting practices to assess workflow; defining the EHR and practice goals; prioritizing needs and opportunities to meet goals; implementing strategies to create positive change; and creating a financial plan for EHR adoption. This experience includes identifying EHR champions, project managers and subject matter experts; developing processes for responsibility assignment, change management, and issue tracking. These skills will be valuable in assisting new practices wishing to implement EHRs and participate in other ABC activities. Evaluation, Performance Monitoring, and Feedback successes. The Albuquerque area also has had impressive success in community-wide health initiatives involving evaluation, performance monitoring, and feedback. These initiatives and their accomplishments are described briefly in the following paragraphs. Each has achieved local, statewide, and/or national recognition for its impact on performance monitoring, feedback to clinicians, and/or impact on quality or cost-efficiency. Related peer-reviewed articles, awards or media articles are provided in the References section. The Clinical Prevention Initiative (CPI), a joint statewide effort led by the NM Department of Health and the New Mexico Medical Society to create a forum for developing statewide clinical prevention policy, promoting prevention awareness and preventive services delivery. CPI has developed workgroups and interventions to address: adult pneumococcal vaccination, tobacco use prevention and cessation, 20

23 mammography screening, colorectal cancer screening, healthier weight, screening and treatment for chlamydia and gonorrhea, screening and intervention for problem drinking, childhood immunization, and prevention of unintended pregnancy. CPI has involvement includes more than 175 individual and 30 organizational members and has contributed to several state health measure improvement. New Mexico Healthcare Takes on Diabetes (NMHCTOD) is a community-wide multi-health plan initiative started in 1999 and supported by NMMRA in concert with the American Association of Health Plans and the American Diabetes Association. Its members include health plans, Department of Health, the NMMRA, local health agencies, and medical and professional societies. NMHCTOD s mission is to improve diabetes outcomes, to maintain a statewide diabetes practice guidelines and to be a state resource. Its work is especially important in New Mexico, where the rate of diabetes is very high among Native Americans and Hispanics, who comprise a significant proportion of the state population. ABC coalition member NMMRA provides the data analysis services for the annual HEDIS diabetes analysis. The accomplishments of NMHCTOD have been featured in numerous presentations locally and at state and national conferences, and the organization has received a number of awards for its excellent publications. The Episodes of Care Disease Management initiative, a nationally recognized program in advanced clinical practice improvement led by coalition member Lovelace Clinic Foundation (now doing business as LCF Research). The Episodes of Care (EOC) Disease Management program was established in 1993 to engage providers in clinical practice improvement by developing teams to research literature for best practice guidelines, identify gaps in compliance with guidelines, provide feedback to clinicians and evaluate program impact. Provider support reports were developed to provide non-judgmental feedback to clinicians, with the objective of fostering system changes for better, more cost-effective care, to reduce exacerbations and hospital admissions, and to provide optimal care for hospitalized patients. 21

24 EOC program successes included: Diabetes: increase in annual glycohemoglobin testing from 43% to 89% and increase in good-optimal glycohemoglobin from 35% to 68.5%; Birth: reduction in Cesarean section rate from 21% to 14%, 50% decrease in NICU days ($441,000 savings annually), and 38% decrease in pre-term deliveries; Asthma: 40% reduction in admissions, 58% improvement in quality of life, 80% reduction in days lost from work and school; and Congestive Heart Failure (telemanagement program): 50% reduction in hospital costs; 29% reduction in overall treatment costs ($5,000 decrease/patient); very high patient satisfaction. EOC leaders, including those at LCF Research, made many invited presentations at national and international conferences, authored many peer-reviewed publications, were the subject of numerous media articles, and received a variety of quality awards. Project ECHO was created in 2004 by Dr. Sanjeev Arora of the Department of Medicine at the University of New Mexico Health Sciences Center. Its mission is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. It is funded by the Agency for Healthcare Research and Quality, the New Mexico State Legislature, and the Robert Wood Johnson Foundation. ECHO enables primary care providers to interact with specialists via telehealth links, in order to care for their more complex patients. Dr. Arora started with an effective hepatitis C program which now serves as a model to treat other complex diseases in rural locations, such as asthma, psychiatry, chronic pain, diabetes/cardiovascular risk reduction, and others. The project has been recognized through a number of awards, most notably the international Changemaker competition sponsored by the Robert Wood Johnson Foundation and the Ashoka Foundation, which designated Project ECHO as a Disruptive Innovation and selected it as one of three winners among 307 applications from 27 countries, which led to a $5 million RWJF award in Aligning Forces for Quality. In April 2009, Albuquerque became one of 15 communities nationwide to participate in the Robert Wood Johnson Foundation s (RWJF) Aligning Forces for Quality (AF4Q) initiative. Nationally, AF4Q aims to: improve the quality of care; engage patients more fully in managing 22