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5/3/2007 1
Opportunities to facilitate community based research through Community Health Center
Tim Long, MD
Andrew Hamilton, RN, BSN, MS
NCRR Meeting May 15, 2007
of Chicago Community Health Services, LLC
What are our goals
04/19/23
1. Promote community based/translational research
2. Develop an information network that can promote research and facilitate translation of evidence based interventions into practice.
04/19/23
Potential of HIT enabled translational research
Description of fully functional Electronic Health Record System in a network of Community Health Centers
State of adoption of Electronic Health Records Systems
Synergies of HIT enabled quality and research
Opportunities for translational research enabled by HIT
04/19/23
Challenges to Research in Clinical Settings
Limited ability to look at population level data to suggest questions
Labor intensity of baseline and study data collection
Inefficiency of subject identification/recruitment Clinical pressures limiting ability of clinicians to
focus on research interventions Limited ability to prompt or support clinicians to
enroll subjects and implement test interventions Logistics limit communication between
academic setting and clinical site/clinicians
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Challenges in the Healthcare Setting
Increasing complexity of Health Care Challenges in coordination/communication
among medical providers and between supportive services and disciplines
Limited time for interactions Difficulty accessing information in
timely/organized fashion for use in decision making at the point of service
Labor intensity limiting population based data to inform system change
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Capabilities of Electronic Record Systems
Basic a storage and retrieval system
VS
Advanced a sophisticated interactive database
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Considerations in implementing higher level functionality
Acceptance of common vision of quality Adoption of evidence based standards against
which to judge care quality Agreement to conform to standardized ways of
recording data
Ability to capture and process relevant data Relevant care elements are captured as
structured information Implies that “order entry” is computerized Data is “clean” and consistent
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What is the Alliance?
BPHC/HRSA funded Network Essentially a joint venture of four
independent organizations with the desire and ability to work together on building some common infrastructure
Ability to access higher quality, efficiency and economy of scale
Dedication to quality Desire to ultimately share with others
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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 where economic, geographic, or cultural barriers limit access to primary health care.
Mission encompasses quality, access, and responsiveness to particular needs of the community served.
04/19/2304/19/23
principal services include: primary and preventive health care, behavioral health care, outreach, and dental care
ancillary services include: laboratory tests, X-ray,
environmental health, and pharmacy services
related services such as health education, transportation, translation, and legal services
currently more than 900 nationally with presidential initiative to increase number
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Who CHCs Serve
91.1% of clients are below 200% poverty
40.1% are Uninsured 63.5% are Racial/Ethnic minority 726,813 Migrant/Seasonal
Agricultural Workers 703,023 Homeless Clients
2/9/2007 11
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CHC Profile
2/9/2007 12
o 952 Community-Based Organization
o 1356 Sites of Care across US
o 14.2 Million Patients Served
o 90,000 MDs/NPs, RNs, & Dentists
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Alliance HIT project goals
1. Implement EHRS in a network of Community Health Centers in a manner that ensures consistency and accuracy of health information across all practitioners, sites and populations.
2. Develop a data warehouse that will monitor, aggregate, and provide data to be used for clinical and system quality improvement.
3. Utilize the EHRS/data warehouse to facilitate and encourage the use of evidence-based practice measures at the point of care.
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HIT project goals
4. Utilize the EHRS/data warehouse to facilitate continuous improvement of health care quality and safety and develop its function as a patient registry.
5. Promote and support the realization of the full potential of EHRS use in ambulatory care settings, particularly among safety net providers, to improve health care quality and safety.
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HIT Partnership
American Medical Association Health Information Management Systems
Society GE Healthcare Clinical Data Services First Consulting Group Health Research and Education Trust Funding agencies:
HRSA ◊ AHRQ ◊ Chicago Community Trust ◊ Michael Reese Health Trust ◊ Robert Wood Johnson Foundation
Commonwealth Fund ◊ Illinois Department of Public Health ◊ Chicago Department of Public Health
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Clinical consensus
Chronic Care Model to manage disease and populations of patients.
Network wide clinical standards. Utilize national experts and evidence
based protocols as basis for standards of care.
Utilize internal/local subject matter experts to review standards and support development of the screens.
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Considerations for EHRS development and implementation
Promote use of standardized templates Structured data entry Ease of data entry to encourage providers
to capture needed information as part of care delivery
Mapping of data elements to care protocols Content to include full spectrum of care (eg,
mental health/case management)
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Consideration for Report Development
Competing/Multiple Performance Measurement Sets with unaligned performance measures.
Lack of Clinical Data Standards for many important medical concepts (such as Foot Exam, Pt. Education, etc)
Inconsistent data definitions across EHR Vendors
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Measure Example
Diabetes Measurement Set (foot exam)
o Measure: Percentage of patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam)
Numerator = patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam)
Denominator = All patients with diabetes 18-75 years of age
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Technical SpecificationsNumerator
Patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam)
Note: All three components must be completed within the reporting period but they do not have to be completed at the same visit.
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Technical SpecificationsDenominator
All patients with diabetes 18-75 years of age
Codes to identify patients with diabetes include: ICD-9-CM Codes: 250, 357.2, 362.0, 366.41,
648.0) (DRGs) 294, 205 Prescriptions to identify patients with
diabetes include: Insulin prescriptions (drug list is available) and
Oral hypoglycemics/ antihyperglycemics prescriptions (drug list is available)
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Technical SpecificationsExclusions
Exclude patients with a diagnosis of polycystic ovaries (ICD-9-CM Code 256.4) who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year.
Exclude patients with gestational diabetes (ICD-9-CM Code 648.8) or steroid-induced diabetes (ICD-9-CM Code 962.0, 251.8) during the measurement year
Patients with bilateral foot/leg amputation ICD-9-CM exclusion codes for 2.9 Foot Exam: 896.2,
896.3, 897.6, 897.7 Other reason documented by the practitioner for
not performing a complete foot exam
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Considerations of Technical Architecture
Hosting in a secure level 3 facility Redundant architecture and secure backup Ability to access system anywhere via
internet Interface engine to build and manage
interfaces Export of data to a data warehouse
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Potential of EHRS & Research
Decision Support Client recruitment Study protocols
Performance Measurement Data collection Study protocols
Remote hosting Communication between study sites Off site intervention
Data warehouse/reporting De-identification of data Aggregation and analysis of data
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Status of System use
Live at main sites of all 4 Health Centers 125 concurrent users, approximately 225
individual users. “Big Bang” - All staff, with full functionality
of the system Productivity at pre-implementation levels Next wave of Alliance sites to go-live
beginning in June Planning implementation at first non-
Alliance sites
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System Use Measures
Adult Use of diabetes disease
management form Use of cardiovascular disease
management form Use of HIV disease management
form Use of Asthma disease management
form Mammogram BIRAD score
documented PAP Results documented Colonoscopy Screening documented
Adolescents Sexual Activity documented at office
visit Violence risk documented at office
visit
Pediatrics Developmental assessment documented Weigh percentile documented Height percentile documented Head circumference percentile
documented
OB/GYN Prenatal visit with documented EDC Prenatal visit with FHR documented Prenatal visit with genetic history
documented
Mental Health Established treatment plan date
documented Treatment plan revision date
documented Signed metal health assessment
documented Substance abuse screening documented
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Performance Measures
AMA/HDC Diabetes AMA/HDC CVD HIV/HIVQUAL AMA/HDC Asthma AMA/HDC Preventive Care
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Can Also Drill Down to Patient Detail cont.
Need to run “Re-ID” macro in Excel to link encrypted patient ID to EHRS patient information
Re-ID will link Pt Name to this #
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Correlation between EHRS elements and research plan
Evidence based practice guideline Research protocolData elements defined Subject criteria, pre and post data elements
End user form designed to provide decision
support at point of patient care Study protocols Measures defined and Data elements mapped
to reports Baseline and study data collection plan
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Benefits of CHC Sector
Representation of disparate populationsComplete spectrum of health servicesStability of service populationQuality orientation – desire to implement
evidence based practice and contribute to improvement
Network infrastructure to support multiple site studies
Experience with HIT