EHR IMPACT ON QUALITY MEASURES AND POPULATION HEALTH IMPROVEMENTS

Transcription

1 EHR IMPACT ON QUALITY MEASURES AND POPULATION HEALTH Kwame A. Kitson, MD VP of Quality Improvement Institute for Family Health 16 East 16 th St New York, NY institute2000.org www. institute2000.org IMPROVEMENTS October 15, 2007

2 IFH AT A GLANCE

3 IFH AT A GLANCE Geographic area Manhattan, Bronx, New Paltz, Kingston, Ellenville, Hyde Park, Port Ewen. 15 Community Health Centers One School Based Health Center Two FP Residency Programs Two Free Clinics for the Uninsured Two Article 31 Mental Health Sites

4 IFH AT A GLANCE Sidney Hillman Walton Urban Horizons Parkchester Mount Hope Westchester

5 IFH AT A GLANCE New Paltz Kingston Hyde Park Ellenville

6 QUALITY IMPROVEMENT NATIONAL DEMANDS DEMANDS ON CHC S National Voluntary Consensus Standards for Ambulatory Care: A Physician-focused Performance Measurement Set. The National Quality Forum has initiated 86 national voluntary consensus standards for measuring and reporting the quality of ambulatory care NCQA: Reviews Health Plan Performance based on HEDIS. HEDIS is the performance measurement tool of choice for more than 90 percent of the nation s managed care organizations. There are over 70 different HEDIS measures ranging from review of cervical cancer screening to smoking cessation and customer satisfaction. JCAHO: Ongoing continuous quality improvement expected.

7 REGIONAL QUALITY IMPROVEMENT DEMANDS ON CHC S Local Departments of Health- HEDIS measures often used. LOCAL Use of Pay-For Performance Quality incentives by PPO s, other medical groups. Internally Driven CQI utilized to satisfy Grant requirements.

8 INFORMATION TECHNOLOGY TOOLS USED TO IMPROVE QUALITY OF CARE Electronic decision support tools Utilization and sharing of reporting data Standardized documentation tools Electronic patient outreach CQI beyond decision support

9 IFH QI READINESS PRE-EHR EHR Access to internal data greatly limited. Resource allocation limited organization- wide QI topic review to three topics per year. Areas covered included comprehensive HIV review, diabetes, adolescent screening for tobacco and substance abuse, postpartum care Interventions that worked best were those that facilitated better documentation by providers (e.g. Stamps)

10 IFH QI READINESS PRE-EHR EHR Average time spent on chart review- 30 minutes to one hour per chart depending on the study Average length it took to complete Pre- EpicCare studies- three months. Chart reviewers were doctors and nurses at our clinics. Time spent on chart review made it more difficult for them to complete other administrative tasks.

11 OUTCOMES IFH transitioned all NYC area clinics into EpicCare between October 2002 and January 2003 Within the first six months provider productivity matched pre-epiccare levels. In 2004 and beyond, unprecedented productivity levels were noted and have been sustained.

12 Outcomes Ease of information retrieval Availability of reports relevant to CHCs Ease of development of custom reports Ease of running ad-hoc reports

13 IFH BEST PRACTICE ALERTS PRIMARILY BASED ON HEDIS CRITERIA PNEUMOVAX SEASONAL FLUVAX BREAST CANCER SCREENING CERVICAL CANCER SCREENING LEAD SCREENING HGBA1C TESTING AND CONTROL

14 IFH BEST PRACTICE ALERTS OPHTHALMOLOGY CONSULTS FOR DIABETICS PEAK FLOW MEASUREMENTS FOR ALL ASTHMATICS NEPHROLOGY CONSULTS FOR PATIENTS WITH GREATER THAN 1.8 SERUM CREATININE LDL SCREENING ANNUAL RPR SCREENING IN HIV

15 DID THEY WORK? Initial concern about the introduction of best practice alerts (BPA s) replaced by enthusiasm for the improvement seen in multiple clinical areas. Keys to Success- Making sure that the BPA s were accurate in capturing services rendered (e.g. There are dozens of CPT codes utilized for Cervical Cancer screening)

16 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% PNEUMOVAX PNEUMOVAX GIVEN PER AGE GROUP VISIT BPA INSTALLED 10/2003 Mar-03 May-03 Jul-03 Sep-03 Nov-03 Jan-04 Mar-04 May-04 Jul-04 Sep-04 Nov-04 Jan-05 Mar-05 May-05 Jul-05 Sep-05 Nov-05 Jan-06 Jan-03

17 Depression Screen with PHQ2

18 LEAD TESTING IN TWO YEAR OLDS % COMPLIANCE WITH LEAD TESTING 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 65% 79% 82% % COMPLIANCE WITH LEAD TESTING

19 PPD Screening of HIV Patients Urban Horizons 15 Month Reports 99% 100% 90% 80% BPA installed February % 70% 60% 37% 43% 50% 40% N= 140 N= 142 N= 186 N= % 20% 10% 0% Apr-03 Apr-04 Apr-05 Apr-06 URBAN HORIZONS URBAN HORIZONS URBAN HORIZONS URBAN HORIZONS

20 RPR TESTING IN HIV PATIENTS ACROSS ALL IFH SITES 80% 70% 4/05 total 10/05 total 4/06 total 60% 50% 40% 10/02 total 4/03 total 10/03 total 4/04 total 10/04 total BPA installed February % 20% 10% 0% 15 month blocks starting from 10/02 to 4/06

21 DIABETIC ROLLING 12 MONTH AVERAGE REPORTS Number DM Patients in Registry Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06

22 DIABETIC ROLLING 12 MONTH AVERAGE REPORTS ROLLING 12 MONTH AVERAGE OF PERCENT OF HBA1C LESS THAN % 60.00% 55.00% 50.00% 45.00% 40.00% 35.00% 30.00% percent of all HbA1c less than 7.5 Linear (percent of all HbA1c less than 7.5) Jul-05 May-05 Mar-05 Jan-05 Nov-04 Sep-04 Jul-04 May-04 Mar-04 Jan-04 Mar-06 Jan-06 Nov-05 Sep %

23 Average HbA1c for DM Patients Average HbA1c for DM Patients Linear (Average HbA1c for DM Patients) Jan- 04 Mar- 04 May- 04 Jul- 04 Sep- 04 Nov- 04 Jan- 05 Mar- 05 May- 05 Jul- 05 Sep- 05 Nov- 05 Jan- 06 Mar- 06

24 HEMOGLOBIN A1C TESTING RATES (TWO A1C) PERCENT OF DIABETICS WITH TWO HGBA1C IN 12 MONTHS Percent DM Patients with Two HbA1c (12 months) Linear (Percent DM Patients with Two HbA1c (12 months)) 25.0 Jan-04 Mar-04 May-04 Jul-04 Sep-04 Nov-04 Jan-05 Mar-05 May-05 Jul-05 Sep-05 Nov-05 Jan-06 Mar-06

25 % OF DIABETIC PATIENTS WITH AN ANNUAL LDL TEST Percent of DM Patients with an Annual LDL Test 70.0% 66.1% 65.0% 62.7% 60.0% 55.0% 50.0% 45.0% Percent of DM Patients with an annual LDL test 40.0% Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Linear (Percent of DM Patients with an annual LDL test)

26 Percent of DM Patients with Ophthalmology Consult Orders 65.0% 60.0% 55.0% 50.0% 46.5% Percent of DM Patients with Ophthalmology Consult Orders (12 months) 62.9% Percent of DM Patients with Ophthalmology Consult orders (12 months) Linear (Percent of DM Patients with Ophthalmology Consult orders (12 months)) 45.0% 40.0% 35.0% 30.0% 25.0% Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06

27 LINEAR REGRESSION OF AVG HBA1c SCORE VS REFERRAL TO NUTRITION XY AVG MOST RECENT HBA1C SCORE VS REFERRAL TO NUTRITION AVG HBA1C SCORE AVG MOST RECENT HBA1C SCORE (01/05 TO 01/06) Linear (AVG MOST RECENT HBA1C SCORE (01/05 TO 01/06)) % 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% RATE OF REFERRAL TO NUTRITION

28 XY GRAPH OF MOST RECENT LDL IN DIABETICS AND PROVIDER SPECIFIC RATE OF UTILIZATION OF ANTIHYPERLIPIDEMICS XY ANTIHYPERLIPIDEMICS RATE TO AVG MOST RECENT LDL AVG MOST RECENT LDL AVG MOST RECENT LDL (01/05 TO 01/06) Linear (AVG MOST RECENT LDL (01/05 TO 01/06)) % 30% 40% 50% 60% 70% 80% 90% 100% ANTIHYPERLIPIDEMICS RATE

29 Syndromic Surveillance

30 DIABETES BEST PRACTICE ALERT SCREENSHOT

31 DIABETES SMARTSET SCREENSHOT

32 DIABETES SMARTSET SCREENSHOT

33 DIABETES SELF MANAGEMENT TOOL SCREENSHOT

34 ELECTRONIC PATIENT OUTREACH 2.0 FTE Outreach/CQI support personnel Initially funded by the great gains received from managed care pay for performance incentives Now also funded in part by grants for various projects.

35 ELECTRONIC PATIENT OUTREACH Telephonic and Mail Outreach are done to 20,000 plus patients per year. TYPES OF OUTREACH Targeted outreach based on internal reporting data. Outreach based on mid-year QARR eligible reports Outreach to patients assigned to our practices that have never accessed care. Outreach to patients who are no-shows for their specialty appointments/procedures.

36 ELECTRONIC PATIENT OUTREACH Major new grant funded CQI outreach effort in 2008 will involve utilizing risk scores for various types of cancer and targeting cancer screening outreach on a risk adjusted basis. LAST_VISIT_ DATE AGE AGE_SCORE LAST_TOBAC tobacco score BMI BMI_ S C O R E ALCOHOL _OZ _PE R_W K A L C O H O L _ S C O R E _SCO R E zzzzzz11 8/13/ Quit zzzzzz12 8/6/ Quit

37 CQI BEYOND ELECTRONIC DECISION SUPPORT Clinical measures reach nadir point. CQI efforts now refocused on clinical and operational areas that impact patient care. Overall goal = Total Quality Management by getting all functional areas and clinical sites involved in local active CQI Back To The Basics Re-examining workflow processes.

38 CQI BEYOND ELECTRONIC DECISION SUPPORT Local Local Clinical Clinical Sites Sites Information Information Technology Technology Operational Operational Local Local Clinical Clinical Sites Sites TOTAL TOTAL QUALITY QUALITY MANAGEMENT MANAGEMENT Local Local Clinical Clinical Sites Sites Administrative Administrative Financial Financial Local Local Clinical Clinical Sites Sites