HIT: Replacing the Missing Link Between Community Health Care and Public Health

THE INSTITUTEFOR URBAN

FAMILY HEALTH

HIT:Replacing the Missing Link

Between Community Health Care and Public Health

Neil S. Calman, MD

The Institute for Urban Family Health

New York City


FAMILY HEALTH About the

Institute for Urban Family Health

• Institute for Urban Family Health – 11 Community Health Centers – – 7 in Bronx, 3 in Manhattan, 6 in Mid-Hudson Valley– 8 homeless healthcare sites in Manhattan– 2 School based health centers– 2 Family Practice Residency Training programs– 250,000 primary care visits / 105,000 patients

• Fully paperless since September 2002• Epic (Verona, Wisconsin) EHR / PMS


FAMILY HEALTH

It is Impossible to Deliver

State-of-the-artHealth Care

without an EHR

1


FAMILY HEALTH

Community Health Centers are a Vital Part of our Nation’s

Public Health System

2


FAMILY HEALTH

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Release

Nu

mb

er o

f C

ases

Symptom Onset Severe Illness

Days

The Benefit of Early Detection of Syndromes

t


FAMILY HEALTH Single patient visit yields complex EHR data

• Patient Address• Race / Age / Gender• Medical history

• Provider Location• Reason for visit• Problem list

• Temperature• Height/weight• Respirations

• Procedures• Medications• Lab results• Diagnoses


FAMILY HEALTH

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Flu isolates

Blue = ER “flu/fever”

Red = Flu “A” isolates

Violet = Flu “B” isolates


FAMILY HEALTH

EHR Fever

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Pe

rce

nta

ge

of

fev

er/

flu

ch

ief

co

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lain

ts

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Pe

rce

nta

ge

of

me

as

ure

d t

em

pe

ratu

resBlue = ER “flu/fever”

Purple = EHR Fever >100 F

Red = Flu “A” isolates

Violet = Flu “B” isolates


FAMILY HEALTH

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f Fev

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nts

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Perc

enta

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bina

tion

synd

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e

Fever AND respiratory syndrome

Blue = ER “flu/fever”

Brown = EHR T≥ 100o and

Respiratory Syndrome


FAMILY HEALTH

Institute patient fevers peaked 13 days before ER visits for Fever and Flu – this indicates that health center data may be the first “signal” of an impending epidemic.

Patients of the Institute for Urban Family Health

Institute fever data responded to Flu B outbreak-ED data did not


FAMILY HEALTH

Community Health Centers can expand knowledge about the community’s

health and use that information to improve its

care of patients

3


FAMILY HEALTH

Provider Patient

Cough!

Step 1: EHR institution to public health agency – clinical encounters

IUFH

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Step 2: Public health agency to EHR institution - epidemiologic awareness

NYCDOH

1

2

DOH receives signal of outbreak of respiratory illness

Practice Alert in EHR for age < 18 yo, cough/fever requests provider to do full cultures and call DOH for immediate pick-up and ID by DOH lab => message in EHR supports Dx of future pts

Cough


FAMILY HEALTH

Few Measurable Quality Improvements Come

from EHRs –Almost All are Facilitated

by EHRs and Cost Real $$$$$

4


FAMILY HEALTH


FAMILY HEALTH

Clinical Decision Support – Impact on Vaccines THE INSTITUTE

FOR URBANFAMILY HEALTH


FAMILY HEALTH

HgbA1c Progress

Average A1c for Past 12 Months

7.5

7.55

7.6

7.65

7.7

7.75

7.8

HG

BA

1C

SC

OR

E


FAMILY HEALTH


FAMILY HEALTH

10 Take New York Indicators

1. Have a Regular Doctor or Other Health Care Provider

2. Be Tobacco-Free3. Keep Your Heart Healthy4. Know Your HIV Status5. Get Help for Depression6. Live Free of Dependence on Alcohol and Drugs7. Get Checked for Cancer8. Get the Immunizations You Need9. Make Your Home Safe and Healthy10. Have a Healthy Baby


FAMILY HEALTHIdentify last

recorded quit date and date of last status

update

FORMER SMOKER BPA PATHWAY

Was last quit date within past 2 years

(or null)?

Was last status update < 90 days ago?

Was last update > 12 months ago?

No BPA activated

NO

YES

NO

BPA #4b: "Update Smoking Status"

YES

BPA #4a: "Update Smoking Status"

NO

Clinician clicks status radio button and clicks verify

button

Was current status updated and verified?

NO. BPA not satisfied.

NO

Store status update

verification date.

YES

BPA satisfied

Clinician clicks status radio button and clicks verify

button

Was current status updated and verified?

BPA #4a not satisfied.

NO

BPA #4a satisfied

Relapse prevention counseling in past 90 days OR quit date > 12 months

ago?

STOP YES

YES

BPA #5: "Review relapse prevention

interventions" NO

Congratulation, you've been tobacco-free for ___ days!

Offer relapse prevention literature.Review current treatment plan


FAMILY HEALTH

Clinical Decision Support – Tobacco Best Practice Alert


FAMILY HEALTH

Patients Seen at Least Once by Their Primary Care Provider


FAMILY HEALTH

Men >35; Women>45 Who have had their cholesterol tested


FAMILY HEALTH

Men >35; Women>45 Who have had their cholesterol tested


FAMILY HEALTHDepression Screen with PHQ2


FAMILY HEALTHDepression Screen with PHQ2


FAMILY HEALTHRecorded Substance Abuse Hx


FAMILY HEALTH Recorded Substance Abuse Hx


FAMILY HEALTHPneumococcal Vaccine >65yrs old


FAMILY HEALTHPneumococcal Vaccine >65yrs old


FAMILY HEALTH

Provider Nutritionist Referral Rate vs. Pts Average HgBA1c

6.5

7

7.5

8

8.5

9

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

Rate of Nutrition Referral

Mo

st

Re

ce

nt

Hg

bA

1C

22

12

1

9

0.9


FAMILY HEALTH

New opportunities emerge to get

information about racial disparities in

health outcomes

5


FAMILY HEALTH

Last Hemoglobin A1c by Race

White 7.03

n=423

Black 7.44

n=2122

Latino 7.86

n=1555

Asian 7.12n=76

6.6

6.8

7

7.2

7.4

7.6

7.8

8

HgbA1c


FAMILY HEALTH

0

10

20

30

40

50

60

70

80

90

Insulin/SensAgent %

1 HgbA1c % 2 HgbA1c % LDL test %

White

Black

Latino

Asian


FAMILY HEALTH

Power to the People

5


FAMILY HEALTH


FAMILY HEALTH


FAMILY HEALTH


FAMILY HEALTH


FAMILY HEALTH

What will the future bring …?


FAMILY HEALTH

Its just the beginning …..

Documents

HIT: Replacing the Missing Link Between Community Health Care and Public Health