Open Door Family Medical Center, Inc. - himss

Davies CHO Award Application Section A: CHO Applicant Identification Form Section A1: Individual CHO Identification Form 1. Community Health Organization Name: Open Door Family Medical Center, Inc.____

2. Address: 165 Main Street_________________________________________________

3. City:_Ossining ___ State:__New York ____ ZIP code: 10562____________________

4. Telephone: (914) 502-1451 Fax: (914) 941-0993

5. E-mail: [email protected] Web site: www.opendoormedical.org_________

6. Name and title of application author: _Lindsay Farrell, President & CEO___________

7. Type of CHO: FQHC__________

8. Member of collaborative entity/health network? Yes/No_No______

9. Number of sites__10__

10. Aggregate number of patient encounters: _169,117 (2009 Year)______

11.

Criteria

% of annual encounters documented in EHR 100%

% of providers/staff using the EHR 100% of the time

100%

Date of Initial Go Live May 2007

Date of organization wide adoption – 100% use by all clinical staff (with reasonably explained exceptions if less than 100%

July 2007

12. How does your EHR implementation align with CMS’s definition of meaningful use as currently understood?

Please explain what you are presently doing in conjunction with your vendor to prepare to meet CMS’ proposed criteria for meaningful use. Meeting CMS’s definition of meaning use does not guarantee award status.

Being recognized as a Level III Patient Centered Medical Home would have been unfeasible without a Certification Commission for Health Information Technology (CCHIT) certified EHR and an effective reporting tool. While eClinicalWorks (eCW) was awarded the CCHIT certification in 2008, their CEO Girish Navani has made it abundantly clear that the product will meet CMS’s standard of meaningful use for each of the upcoming three phases in 2011, 2013, and 2015. As of this writing, eCW already fulfills the proposed meaningful use Stage 1 objectives. We are confident that the EHR will remain aligned with meaningful use standards. Meaningful use, as with Open Door’s Level III Medical Home recognition, required significant staff education and workflow changes. At the most basic level, Open Door achieved a paradigm shift moving away from a practice focused on the “tyranny of the urgent” to one focused on planned care. EHR technology and electronic reporting capabilities facilitated the transformation. Many of these accomplishments are described in this application and include: establishment of provider panels and ensuring patients are consistently seen by their primary care provider; clinical performance metrics for populations of patients with chronic disease; clinical decision support for care teams at the point of care; patient registries; e-prescribing via Surescripts; electronic referral management; and electronic care planning capabilities, just to name a few features currently used. The near-future addition of a patient portal and e-messaging features will further allow Open Door to engage patients and use our electronic information system more meaningfully.

This Davies application summarizes how we implemented our system and the myriad ways Open Door meaningfully utilizes electronic health information to provide safer, more effective care to our communities, delivering value and good health that benefits both patients and tax payers. 13. Services Offered: Direct (Yes/No) Referral (Yes/No) N/A Adult Medicine Yes Pediatrics Yes Women’s Health Yes Dental Yes Radiology No Yes Laboratory Yes Yes Mental Health Yes Yes Emergency Care No Yes Urgent Care Yes Yes Pharmacy No Yes Other Services Yes Yes 14. Staffing (Number of full time employees):

Staffing (number of FTEs) 226.14 Physicians

15.04 Psychiatrists 0.39 Dentists 6.89

Physician Assistants

1.80 Nurses (RN/LPN 15.59 Other licensed clinicians 11.17

Nurse Practitioners

8.48 Medical Assistants

37.26 Information systems staff 2.00

Lab Technicians 2.00 Dental Hygienists/ Technicians

17.26 Other FTEs (administrative, executive, fundraising, etc.)

53.90

Imaging Technicians

0.36 Other medical personnel

37.46 Care managers 9.81

Certified Nurse Midwives

5.00 Other mental health staff 1.75

15. Describe hospital affiliations: Open Door Family Medical Center maintains affiliations with the Stellaris Hospital system which includes three community hospitals in Westchester County – Phelps Memorial Hospital Center, White Plains Hospital, and Northern Westchester Hospital Center. In addition, we are affiliated with the tertiary care hospital for many specialty services in the area – Westchester Medical Center in Valhalla, NY. 16. Provide detailed information regarding any commercial/employment agreements with the vendor/s of EHR hardware/software: Open Door has no commercial or employment relationships with any EHR vendor. 17. Names and titles of EHR implementation team: Lindsay Farrell, President & CEO_______________Daren Wu, M.D., Chief Medical Officer__________ Eugene Market, COO_________________________Pam Ferrari, RN, Dir. of Performance Improvement Maria Mazzotta, CFO_________________________Ellette Hirshorn; Dir. Of Clinical Support________ Maralee Walsh, PhD., Dir. of Behavioral Health____Donna Goldbloom, Business Analyst____________ Arturo Barletta, IT Manager Will all be considered as authors of the application? No If not, who will be considered as authors? Lindsay Farrell, President & CEO

Open Door Family Medical Center, Inc. 2010 Davies Community Health Organization Award Application May 14, 2010 1

**As is custom, and at the request of HIMSS, additional information revealed during the finalist site-visit has been included in the following narrative and appendices that were not contained in the original submission. Supplemen- tal information in the body of the narrative will be marked as such with a double asterisk. Five charts provided to the HIMSS reviewers during the site-visit can be found directly after page 25 of the Appendices.** 1. Populations: Anticipated Impact for Patient Populations Served Open Door Family Medical Center, Inc. (Open Door) serves the under-served, uninsured and underinsured residents of Westchester County, New York. While the county is home to about one million people, Open Door’s patient base of almost 35,000 consists primarily of the working poor: low-income working families and vulnerable populations such as Latino immigrants, women and children who are never turned away from care. Over 92% of our patients have incomes at or below 200% the federal poverty line and more than 55% have no health insurance of any kind. Without the critical safety net of Open Door, local emergency rooms would be the only place for many to obtain care. The health status of Open Door’s target communities is marked by higher incidences of morbidity and mortality. Data from the Westchester County Department of Health and the Center for Disease Control indicate infant mortality, low birth weight, teen age pregnancy, diabetes, tuberculosis, sexually transmitted disease, cardiovascular disease, asthma and HIV/AIDS are more common than in other areas of the County. While improving, the disparity of morbidity and mortality rates between whites and ethnic minorities persists in our service area. Open Door’s target population is predominantly comprised of recent immigrants from Latin America – primarily emanating from Ecuador, Guatemala, Columbia, and Mexico. Frequently, these immigrants have left countries that were affected by war or civil disruption in addition to extreme poverty. Because of the high cost of area housing many low-income families are forced to double or triple up in one apartment. Parents and children grapple with acculturation issues and are challenged by a lack of basic literacy skills, even in their native language. Many have not completed high school. Mistrust of institutions and fear that immigration status could be compromised are issues Open Door must constantly address. News in the community of random raids by Immigration and Customs Enforcement that break apart families is all too common. As a result, unique barriers to care cause misuse and under-use of health care services. All of these factors result in a population that has significant and distinct health care needs, addressed in systematic ways at Open Door, an established federally qualified community health center and a recognized Level 3 Patient Centered Medical Home by the National Committee on Quality Assurance (NCQA). Impact of EHR on Meeting Health Needs: Open Door has utilized electronic information tools to systematically improve the care it delivers for more than ten years. Employing a population health approach to define and monitor our target populations, supporting providers with care alerts and clinical decision support at the point-of-care have been hallmarks of Open Door’s improvement efforts. From the (free) PECS registry populated by data extracts from our Medical Manager practice management system, to robust use of the eClinicalWorks (eCW) fully integrated system along with a data warehouse solution known as BridgeIT, Open Door has experienced practice transformation that is delivering real value to its providers, patients and the community. The technology has: Improved Quality and Access to Care: Before implementing eClinicalWorks, Open Door was challenged to move paper charts from one site to another to follow the patient. With the EHR implementation, each patient has one chart accessible at all of our locations and our collaborating hospital where our prenatal patients are delivered. In addition, providers are provided access to critical information at times that the centers were closed. Improved Disease Management: The ability to identify high risk patients and patients with chronic illnesses, and to support the physicians in care planning and reminders at the point of care with recommended order sets and embedded clinical decision support has allowed us to make significant improvement in patient and population health outcomes. Point of Care Quality Improvement: The ability to embed order sets, use structured data, recommend clinical guidelines and alert busy clinicians encourages the delivery of evidenced based care across our system. Continuity of Care: The ability to track both orders and results for all laboratory and diagnostic imaging procedures improves transitions of care and provides important tools for follow-up. A bi-directional interface with laboratory vendors improves the timeliness of reporting results to our clinicians and patients.


Patient Safety: ePrescribing provides information about medication interactions and facilitates the patient’s ability to obtain the correct medication. Electronic documentation of all telephone encounters improves communication amongst the care team. Community Care Coordination: Record availability over a secure network improves care coordination during after hours on call, hospital rounding, and at other times when the provider is not at a practice site but needs to render medical judgment. 2. Purpose: Organizational Description, EHR Program Objectives Mission Statement: The Mission of Open Door Family Medical Center is to provide quality primary health care and human services at affordable prices to the community, particularly the economically disadvantaged. The core values for the organization are: (1) We believe that health care is a right, not a privilege; (2) We believe in diversity and respect cultural and linguistic differences; (3) We believe that healthy individuals and families are the foundation of civil society; (4) We believe that individuals empowered to lead healthy lives contribute significantly to the community's success. Open Door Family Medical Center, (Open Door) a federally qualified community health center, began operating as a free clinic in 1972 in Ossining’s First Baptist Church. Local volunteers recognized the need to provide health care services to the poor and after a few years the group began planning for a comprehensive primary health care center which moved into the current Main Street Ossining location in 1976. Since its beginning, Open Door has sat at the intersection of public health and private practice. To provide access to care to low-income people in Westchester County and to address health disparities between those with access to health care and those without, Open Door expanded its services and reach through the years to include health centers in four low-income villages within the County, as well as four school based health centers, a mobile outreach van to find the hard to reach populations that are at risk for HIV/AIDS, and a dental van. Open Door’s service delivery model includes primary medical, dental, and mental health, WIC, and outreach and educational programs in collaboration with many of the social service agencies and the department of health in our community. Open Door’s goals for implementing the electronic health information platform stem directly from our commitment to performance improvement, population health and organizational excellence. As a Joint Commission accredited health center and an NCQA Level 3 Patient Centered Medical Home, Open Door embraces a robust information management strategy to achieve care quality and operational efficiency to deliver value to our communities.

That commitment is built upon experiences gained during our visit re-engineering and disease management collaborative that began in 1996 and 1999. These efforts initially focused on making process improvements by obtaining, measuring, analyzing, and sharing data extracted from our Medical Management practice management system imported to a registry system, PECS, and reducing visit cycle-time. The implementation of a fully integrated electronic health record with data extraction capability enabled Open Door to evolve from a center devoted to managed chronic care to planned care and now to a Patient Centered Medical Home focused on coordinating care by a trusted provider and team coordinating care across the health continuum. Today with eClinicalWorks and a data warehouse populated using BridgeIT, (an application used to extract data and report on it) we have virtually complete access to our clinical, financial and operational data. Open Door’s leadership in robust use of eClinicalWorks stems from our own organizational culture along with our quest for excellence supported by grant funding to investigate and measure whether the use of clinical decision support in an electronic health record improves the care of our patients with hypertension. 3. Personnel: Leadership, Governance and Key Staff Leadership: Leadership was a critical resource in the seven year HIT planning and learning process, creating the right conditions for Open Door's very successful and rapid eClinicalWorks adoption. Leadership remains an essential ingredient as we move toward information exchange with our partners and collaborators. Concerning implementation, eClinicalWorks’ practice management system was completely deployed at Open Door in April of 2007 after purchase commitments were made in December 2006. The electronic medical record was completely deployed six weeks later in June 2007 to all of our clinical sites. The entire organization was fully live with the complete product in just eight weeks. The rapid adoption by our provider and support staff


exceeded our expectations and was a testament to our implementation planning and our healthy organizational culture. Three years later, monitoring how providers and staff use the system via BridgeIT reports, plus regular feedback from the clinical staff and staff across the organization, facilitates standardized and effective use of eClinicalWorks. This on-going auditing and reporting capability provides insight about system use and facilitates quality improvement efforts.

Health Information Technology (HIT) and the information provided from the data captured in an electronic system was always seen by the leadership as a means to accomplish our quality goals and business objectives. Senior Management placed HIT front and center with regular staff communication about this focus and all throughout facility preparation and wiring, the vendor selection and implementation process. Open Door maintains a structure for regular internal communication which keeps the organization aligned and focused on our goals, and strategic objectives. This internal communication supported the roll out of the new system, and continues today to support our efforts to improve use and knowledge about improvements to our EHR. EHR Program Leadership: The Implementation Team for our eClinicalWorks project included all Senior Managers, the Business Analyst/ Project Manager, the IT Manager, along with the local leadership at each site, (the practice administrators and medical directors), who set the tone and made sure that every one was on the same page. While each department and site had regular meetings, it was our formal, local multidisciplinary team approach that laid the ground work for our successful EHR implementation. The buy-in for EHR implementation was organization wide; every one at Open Door knew that an EHR would impact the clinical, financial, and strategic direction of the organization for years to come because this was communicated to all staff. Senior Managers made mutual commitments to one another to be successful and knew the workdays would be long. We "huddled" early each morning as we rolled out eClinicalWorks across the Open Door, sharing concerns and coming up with specific strategies. We modeled the behavior we wanted to see from the rest of the staff as we worked across the organization and alongside staff in every site and pod. While the development of the system was centralized, we knew that the local approach would be essential to the overall operation and implementation of the system. Patient care teams/pods led usually by a physician, met regularly to discuss their challenges and improvement strategies. While initially pods convened to focus on specific projects like workflow redesign and chronic disease management, we institutionalized the approach to keep the organization humming. Agendas and minutes document the work and keep every one focused and the use of data and information are an important aspect of the time spent together. Pod meetings are and continue to be the backbone of Open Door's learning culture and an important vehicle for sharing and knowledge. They require continued commitment and strong local leadership. Once the dust from implementation settled, Open Door celebrated together as we had successfully met our target of rolling out the practice management and the electronic health record in eight weeks. In 2010 Open Door has been focusing on “advanced” use of integrated health information technology, and has planned regular training sessions for the clinical staff, the front desk, and billing staff. We are designing 3 to 4 hour training sessions provided in a training room, because we believe this will continue to improve work flow, and as our vendor continually works with users to improve the system, we have to provide this information to the front lines. On-going training, both formal and informal, will maximize the benefit of HIT. IT Governance: Governance of our IT functions is evolving as Open Door participates in numerous HIT networks and collaborations while moving with our community towards Health Information Exchange. In 2009, the organization recognized that the continuous upgrade of technology, the communications infrastructure, and the need for redundancy and availability for our core applications 24 hours per day, 7 days per week, required a small organization such as Open Door to work with other organizations for increasing our knowledge to support our investment and to meet our expanding dependency on the technology. Our users demanded this from the leadership. During this time, our vendor, eClinicalWorks, recognized that the federally qualified community health centers required different needs, and worked with the National Association of Community Health Centers, NACHC, to develop a national steering committee to identify needed enhancements for billing, clinical documentation, dental, behavior health, reporting, and infrastructure issues now that many organizations had used


the system for three or more years. Open Door’s leadership participates and chairs many of these subgroups, influencing national steering committees and pushing vendors to bring needed modifications to programming and software. Besides involvement with the vendor and NACHC, health information technology has a local and state focus for improved health outcomes for our patients. At this level, Open Door participates with the Taconic Health Information Network and Community (THINC) RHIO, the regional health information organization focused on health information exchange for the Hudson Valley. Open Door CEO Lindsay Farrell was recently appointed to its board. The RHIO has received funding to support development of a standardized Continuity of Care Document that moves across the continuum of care amongst aligned health providers in the Hudson Valley such as community health centers, hospitals, private medical groups, nursing homes, home care agencies, and insurers. Open Door’s CEO, CMO and Director of Performance Improvement & Clinical Knowledge all participate in the RHIO’s Medical Council. This involvement, to expand the use of health information technology and the benefit of sharing knowledge and outcome data with organizations serving under-served communities, continues to provide improved knowledge for operating and maintaining our own technology. At the level of serving the patient communities, Open Door’s governance is working with sister centers and the THINC RHIO to provide for expanded information exchange of laboratory results, hospital admissions and discharges, and for our diabetic patients’ improved care coordination when transitioning across the continuum of needed services with specialists and hospitals. IT and HIT functions require a broader understanding of resources available since the health environment is beginning to recognize our dependency on this ‘new utility’ for improving health. Board of Directors: The senior leadership at Open Door has been working on EHR development with the governing board of the organization since the strategic plan of 2005 was developed. Open Door’s governance structure includes a 21 member community Operating Board that meets monthly; 51% of the Operating Board members are patients of the center. The Open Door Foundation Board includes 15 members who lead the fund raising and asset management efforts; they meet six times per year including twice jointly with the Operating Board. Board committees most involved with the electronic health record included the Strategic Planning Committee who along with the Senior Management Team shepherded the development and writing of the strategic plan. The Board and senior staff spent a year assessing the dynamic health care marketplace. Having been first vetted by the Board’s Finance Committee, the full Board approved the purchase of eClinicalWorks in December 2006 and understood its return on investment and impact on the 2007 operating plan, capital spending plan, projected cash flow and forecasted balance sheet. At the most recent Strategic Planning session in 2010, the Board Chair recommended adding a new committee focused on working with the staff on the needs for privacy and security in an increasingly electronically connected health environment. Clinical report cards are presented to the full Board at least quarterly by the Board’s Performance Improvement Committee. Through a grant-funded hypertension project (Appendix 4 – Overview of AHRQ Grant), the full Board has become more aware of HIT functionality including clinical decision support at the point of care to enhance evidenced based care and structured data which allows for health information exchange. The Board has had presentations about the national NHIN and New York’s SHIN-NY to enhance their awareness about the future of health information exchange and its impact on Open Door and our patients. In 2009, the Board of Directors approved a capital Information Technology budget which includes expanding patient access to their health information through the eClinicalWorks patient portal and eMessenger functions. In addition, the preparation for and the recognition as a Patient Centered Medical Home has continued to expand the Board’s understanding of the importance of technology for patient care, access, safety, quality, and outcomes. 4. Partnerships: Collaborations for Community Health Open Door took advantage of a number of important collaborations as it planned, learned, implemented and refined its electronic health information systems. At the planning stages, a $650,000 grant from Hudson Health Plan, the Medicaid managed care plan that was founded by Open Door and sister health center Hudson River Health Care twenty years ago, secured for us a dedicated source of capital funds for the EHR purchase and initial training costs. Since Open Door is the plan's largest provider and has a robust pay for performance program, the implementation of an electronic health record was in our mutual interest, a phrase that is continually repeated when it comes to EHR and partnerships. The more involved we became with partners, the easier our process was.


As our learning and planning stage progressed, the Take Care New York project in New York City had a significant impact on our vendor selection. This was an informal partnership and we were in close communication as more and more centers in New York City went live. We have shared our learning with our colleagues at the New York City Department of Health and participate in a number of clinical and practice management workgroups. As the New York City effort was developing, our primary care association worked closely with community health centers in New York to organize a Primary Care Health Information Collaboration (PCHIC) to work with the city health centers beginning to implement EHRs. With our primary care association CHCANYS, the Community Healthcare Association of New York State, Open Door and several other community health centers formed the Health Center Network of New York (HCNNY) and received a network health IT grant from HRSA. The vision for the network is to position its health centers as coordinators of care across the health care system continuum by facilitating HIT Implementation & Support, Quality & Operational Improvement, and Advanced Network Services for member health centers. This partnership was focused around putting centers on the road towards a health IT-enabled medical home, and helping and sharing with each other along the way. With EHR implemented in member centers, aligning clinical priorities among members can be tackled, as well as leveraging value-added services, such as clinical decision support and robust care coordination around specific diseases. Perhaps most exciting, HCNNY will enable patient and population level clinical data aggregation which allows for honest, real-time comparative analysis between member centers. With that knowledge, unattainable without EHRs and dedicated collaboration, best practices can be identified and shared, health trends targeted and addressed, and new strategies evaluated on their results. Open Door is a founding member of HCNNY, and our CEO continues on as a board member of this organization to set the strategic focus for HCNNY. Efforts are underway now to incorporate HCNNY as a separate organization, and each of the founding members have had to commit not only time resources but financial resources to enable this to happen. Several of the senior staff at Open Door participate in HCNNY meetings or chair committees for this organization which supports the operational, financial, and clinical needs of the members to improve our knowledge and use of eClinicalWorks. With a sister health center as the lead applicant, Hudson River Health Care based in Peekskill, New York, Open Door collaborated and applied successfully for HEAL V funding from the New York State Department of Health to establish the health information superhighway in the Hudson Valley. These applications funded a consortia of community based providers aligned with RHIOs. Open Door and Hudson River are the community health center members of the pioneering THINC RHIO in Fishkill, New York. We applied successfully for additional funds from the State’s HEAL X program for 2010 to further pave the SHIN-NY with robust health exchange capabilities and support to assist in practice transformation related to medical home certification. This project recognizes that linking the patient to their health care information and engaging them in their care is an important and necessary aspect to the patient centered medical home. The group’s current focus is working with hospital partners on the creation of an electronic Continuity of Care Document, and figuring out together what are the critical values that need to be readily accessible across the continuum to ensure efficient, safe care. We collaborated on a successful funding application to the Agency for Healthcare Research and Quality (AHRQ) with the Primary Care Development Corporation (PCDC) and our research partner, Columbia University during our implementation and into our refinement stage of EHR deployment. The proposal studies care of hypertensive patients at Open Door and whether or not care improves through the use of clinical decision support embedded in the electronic health record. Our clinical decision support intervention is closely tied to the Take Care New York module developed by eClinicalWorks and the New York City Department of Health. Open Door physicians were actively engaged in the development of the treatment algorithms that comprise the enhanced clinical decision support. This was a 3 year partnership that forced us to really dig in and use the EHR in a dynamic way. While this collaboration is not yet over, hypertension outcomes have already improved significantly. (See Appendix 1 Clinical Outcomes, Appendix 2 Hypertension Intervention User’s Manual, and Appendix 4)

Partnerships provide a vital source of strength, as Open Door optimizes the system’s capabilities and functionality. As a Patient Centered Medical Home preparing for meaningful use, we find we have much to offer and to learn from our colleagues and partners. As a participant in eClinicalWorks’ national health center users group, we realized that having health centers unify and speak with one voice improves our collective


effectiveness, and the response time from our vendor for focused application improvement and development needs. Open Door took a lead role in forming the national eCW Health Center Steering Committee that has and continues to work to unify our voice and develop common priorities for the vendor to address. Areas that have been directly touched upon by the Steering Committee include the development of dental and mental health modules that would be fully integrated with the electronic health record, needed improvements to the application’s report writer (known as EBO), and improved guidance regarding hardware and network specifications. Our vision is that an effective partnership between health centers and the vendor makes the product better, makes eCW more effective in responding to our needs, and helps to make all parties work smarter. ** As CEO, Lindsay Farrell is constantly striving to position Open Door as an innovator within the broader community to demonstrate the value we provide to the communities served and to press for needed health care transformation. As a member of the Board of THINC, the region’s RHIO, she is able to demonstrate how effectively health information technology supports proactive, planned, population-based care and care coordination in federally qualified health centers; this in turn drives transformation in other primary care settings in the region. Lindsay is a founding member of the steering committee of the national community health center eClinicalWorks’ users group. While initially focused on change management relating to health centers’ adoption of electronic health records, she is currently leading the charge to provide more structure to the users group by writing rules of participation and by-laws. It is hoped that formalizing the national users group will improve communication and permit it to work more effectively with the leadership team at eCW by prioritizing health centers’ development requests, reporting requirements and developing improved training and implementation processes. The group is also addressing eCW’s system architecture by understanding the array of issues related to network communication, hardware and database layers. Most notably, Lindsay led the charge to encourage eCW to develop an improved report-writing structure more suitable to the needs of health centers. While eCW offered Crystal reports and its APL and EBO report writing options, none met health centers’ on-going needs and the user community was desperate. Crystal Reports was too difficult for most health centers to learn and APL and EBO reports were extracted from the production database and didn’t allow drill downs or data validation. Lindsay educated the health center community about Extract, Transform, Load queries/data extraction tools with data warehousing as a better option. At its May 2010 health center users meeting, eClinicalWorks announced its new Cognos Analysis Suite and data warehouse format to better address the reporting needs of health centers. She serves as the treasurer of HITCH (Health Information Technology for Community Health), a new organization related to New York State’s HEAL 5 and 10 programs devoted to improved electronic care coordination in the safety net in the Hudson Valley. Additionally she is a leader and founding member of the Health Center Controlled Network of New York and serves on its finance committee. This network received notice yesterday that it will benefit from an additional $3M to implement EHRs in several additional health centers as well as enhance applications in its existing members. ** 5. Preparation: Readiness and Workflow Open Door spent about seven years preparing for the advent of our electronic health record. Joining HIMSS in 2002 and attending annual conferences provided important resources for learning, studying the vendor landscape and moving Open Door forward. MGMA also become another resource that allowed for knowledge sharing with other medical practices. Computer knowledge and keyboarding skills were adequate prior to implementation thanks to our Outlook email communication system and desktop applications deployed in advance of the electronic health record. Internal training has been available on Outlook since the late 1990s. Once we contracted for the EHR, we worked closely on our staff training plan. A capital spending program allowed Open Door to plan for and finance the infrastructure - network development; cabling/wiring, air conditioning, hardware purchasing, and space assignment which resulted in the installation of computers in every exam room, nursing station and patient service area across the entire organization. We worked closely with our selected vendor, eClinicalWorks on a detailed hardware specification, network and communication plan, testing and implementation plan.


Knowledge of workflow re-engineering has been an important operational skill that is regularly deployed to analyze cycle times, wait times, registration sequences, claims processing, tracking of referrals, etc., with the ultimate goal of minimizing hand-offs. Improvements made have enabled Open Door to bring services to the patient, rather than asking the patient to move from station to station. As a result, Open Door’s culture embraces on-going improvements and adaptable workflows.

The fact that we were implementing a unified practice management and health information record required that the organizational leadership work outside their “silos” and share information to understand work flow processes for the ultimate success of our project. The clinical leadership, our CMO, Director of Clinical Knowledge, and Director of Clinical Support, then had a better understanding of the financial and operational processes while finance and operational staff at the senior level and local sites now had a broadened understanding of clinical work flows that would eventually impact on creating a claim and influencing our financial performance. Significant organizational learning focused on quality improvement, chronic disease management and planned care. Our ability to manage populations of patients with the old PECS registry was an important advancement at Open Door, one that is closely tied to the way we utilize the electronic health record. Clinical care teams utilize data and information to monitor, track and follow groups of patients of similar age or conditions. A clinical report card has been produced since 2004, shared with Board and provider alike. A fully functioning eClinicalWorks registry and structured data sets in version 8.0 facilitate data aggregation. The use of BridgeIT to develop custom needed reports for managing our operation – clinically and financially, have assisted Open Door to continually work towards improvements that benefit our patients and streamline administrative processes. Besides the informal education provided at multiple meetings throughout the year, structured formal trainings on enhancements or changes to the system continue to benefit our staff. 6. Purchasing: Vendor/System Selection The decision to select and purchase eClinicalWorks resulted from a multi-year search that began at the HIMSS conference in 2003. We reviewed vendor surveys and evaluations written by the American Academy of Family Physicians and the California Healthcare Foundation, among others. To narrow down the field, we used the HIMSS Ambulatory EHR Selector, an on-line database of certified EHR products and vendors that provides a comparative analysis of more than 375 characteristics.

From this review, we identified preferred vendors and invited them for a formal on-site demonstration. Based on deteriorating support from our existing practice management system, we were convinced that we needed to find a unified solution – practice management and EHR. Later, we conducted vendor sponsored site visits to see the products in a live medical practice environment. Finally, we identified sites using the product on our own and went there without the vendor's knowledge. By 2005 we selected two contenders to submit formal pricing proposals but because their costs were beyond our reach we needed to defer our technology plans at the time. In 2006, we looked at EPIC in collaboration with the Institute for Family Health in New York City, a community health center under the leadership of Dr. Neil Calman, a previous HIMSS award winner. Again, we found this solution to be prohibitively expensive. We understood the benefits of registries and thought that a bi-directional interface between our practice management system and a registry could provide an intermediate solution, but the lack of support and performance from the practice management vendor indicated that this alternative would continue to be a threat to our operation and bottom line. As an active participant with our primary care association, CHCANYS, we became aware of eClinicalWorks and knew of their contractual plans with the New York City Department of Health. We did as much research as we could about eClinicalWorks' success in Massachusetts deploying numerous physician practices as a part of a regional grant-funded HIT initiative in North Adams. We visited Community Health Center of Connecticut and Urban Health Plan in the Bronx, two centers live on the eCW electronic health record, with whom we had participated in diabetes and cancer screening learning collaboratives. ECW received excellent reviews from these colleagues whom we really trusted and both had fully functioning lab interfaces as well. As noted in the “Partnerships” section, we also learned a lot from Take Care New York. We learned about what was being planned in New York City concerning information tracking that would be developed in the then upcoming version (8) of eCW to provide a strong population health approach at city clinics and other community health centers.


The project was innovative and exciting. Another health center, Whitney Young in Albany, was on a parallel vendor selection track and we consulted with them to check our thinking as well. All of the products we looked at required configuration and development to mesh with our health center. Taking into account the nature of our practice, eCW presented a smoother configuration than most. Products more hospital oriented would have taken more development than eCW, based on our respective size and scope. ECW project managers promised a tailored roll-out schedule with benchmarks for installation, practice management, the EHR, and lab interface ready-to-use dates. Given our relatively old IT infrastructure at the time, including desktop workstations older than five years, and outdated routers and switches with lower bandwidth WAN links, hardware/network upgrades would have to have taken place regardless EHR vendor. ECW also promised a personal Project Manager and implementation team, with specialists for each area of the product, e.g. billing, interface, reporting, etc., dedicated to our practice’s implementation for technical support, which would prove valuable. Agreements would be put in place guaranteeing maintenance and updates, including a “test box” or “sand-box” for our own implementation team to play with and make sure any new updates or patches that came through work on the ground, on our own computers. After an on-site demo at Open Door by eCW CEO Girish Navani and reviewing price quotes we were convinced that eCW was the way to go. Our transformation began. 7. Product: Software/Functionality/Interoperability/Hardware/Networks Software Applications: eClinicalWorks is a fully integrated physician office application that includes a practice management system for appointment making, telephone messages, billing and claims submission and an integrated electronic health record with organized summary information about the patient, clinical alerts, care templates that can be customized, knowledge bases and clinical decision support. The practice management component streamlines charge entry and billing processes and allows patients and physicians to communicate easily, safely, and securely over our network for aspects of their care including appointments, lab results, and medication requests and refills. The electronic health record component enables us to manage patient flow, immediately access patient records in-house or remotely, and enables providers and support staff to access and review complete patient histories, past visits, current medications, allergies, labs, and charts. Care prompts, alerts, decision support mechanisms, and electronic registries also help to ensure care delivered is safe, evidence-based, and of the highest quality. Functionality: Open Door has been aggressive and remains at the forefront of product utilization with our eClinicalWorks software for both electronic medical record and practice management. Since implementing the EHR and entering the third year of use as a Level 3 Patient Centered Medical Home, Open Door uses software functionality to care for our patient population. In 2009, we strengthened our use of clinical decision support, order sets, and structure data. This is reflected in the improvements in the physician report cards that are reviewed monthly, and shared with our clinicians at least quarterly. ECW allows the organization to track orders, diagnostic imaging, and referrals to outside organizations, records all medications along with providing alerts for possible drug interactions, and allow our clinicians to submit electronic prescriptions. Patient advocates regularly utilize the registry functions to identify and coordinate care for our patients with chronic illnesses, as well as provide for proactive outreach for preventive care services. While we currently use an electronic reminder call system, PhoneTree, we believe transitioning to eMessenger will improve efficiency for recognizing appointment availability. We have begun preparations for the Patient Portal, including increased recording of patient email addresses, and learning about their access to computers and the internet. Recognizing that coordinated care requires an exchange of information, Open Door implemented a work improvement process with the local hospital to identify appointments provided for specialty services, return of the consultation report, and identification of all missed appointments. This information is scanned into our record and the clinician is alerted and able to follow up with the patient on the importance of these consultations. This is a step towards initiating the P2P (Peer to Peer) functionality with our area hospitals. Since not all our specialists or area hospitals are on the same electronic record platform, P2P should assist in the exchange of needed information until the full health information exchange is implemented in the Hudson Valley and the entire New York state. Integration/Interfaces: Open Door has a bi-directional lab interface between eClinicalWorks and two lab vendors, LabCorp and Bio-Reference. This provides ease of ordering and results return directly into the patient's medical record. ECW has developed an interface with Dentrix, our dental record application, which allows new


registrations, demographic updates, and appointments to be made in eClinicalWorks which update the Dentrix system. Our clinicians have been utilizing the e-prescribing module which is connected with RxHub and Surescripts since March 2009. Prescriptions are more often electronically transmitted to the local pharmacies with a click of a mouse, and we believe that the NYS Medicaid incentive payments which begins in May 2010 will prompt our physicians to increase their e-prescribing from 50% of all prescriptions documented in the system going electronically at this time, to reaching our goal of having at least 80% of the prescriptions transmitted. Open Door maintains an interface to the NY State Immunization Registry for all children, allowing other organizations to have immunization information and assist our clinicians when the family does not recollect past vaccinations. Outside reports from specialists are received into a fax server and electronically assigned to the ordering provider for review with a click of a mouse. Open Door has improved its ability to capture key health indicators, financial reporting, and clinical performance using reports written with our BridgeIT graphic user interface. We can now compare three years of data on our patients. Our performance improvement plan in 2009 focused on data integrity and validation, and these efforts have resulted in a reduction in incorrectly entered information into our EHR. Version 8.0 has provided us with the Take Care New York population health enhancements including structured data sets, smart forms, and order sets that will support chronic disease and planned health care. In preparing for our Level 3 Patient Centered Medical Home certification, eCW and our BridgeIT software allowed us to demonstrate our accessibility, communication with our patients, use of information to manage our patients’ care, and our ability to monitor our own performance in relation to established guidelines, policies and national benchmarks. In 2010, Open Door has contracted to develop clinical summary exchange with our hospital affiliates through THINC RHIO, the regional health information organization in Hudson Valley. With our next upgrade of the software, Open Door will be positioned to begin exchanging the standard Continuity of Care Record documentation promoted through the federal Meaningful Use criteria. Developing/improving information exchange with our hospitals and specialists across the health continuum providing services to our diabetics, through NY State DOH’s resources and efforts to expand information exchanges, will also be a focus in 2010. Connectivity/Networking: Currently, Open Door's network infrastructure supports four health centers along with five school based health centers, our mobile outreach unit and our mobile dental unit. The connectivity has been upgraded to a fiber link for our data information flow through Verizon while retaining a redundant MLPS link through Paetec Communications. Paetec provides our primary internet communication through their “cloud” and our primary support for voice communication. This allows for redundancy, expansion of our connections, and allows for prioritizing both data and voice. When either communications system is non functional, the network automatically switches to the other working communication network. At the time of our initial eCW implementation, we purchased three application servers, two database servers, one report/FTP server, one fax server and one test server. Over the three years on the EHR, we have identified challenges with our original hardware configuration, and have worked with several collaborators to evaluate ways to improve speed and connectivity without incurring large capital expenses. (Appendix 3 illustrates the old configuration for our sites before we moved data to the Verizon network, as well as the configuration for our cloud utilization with Paetec as of 2010). Our school based health centers are tied in with ADSL links and our mobile vans access the servers through wireless connections. These connections support the over 300 PC’s deployed organizationally. We continue to provide our providers the flexibility of a highly secure VPN connection from anywhere; allowing them to have access to health information when on call or out of the office. In 2010, Open Door implemented a disaster recovery site at Port Chester which allows for redundancy for our electronic medical record, dental record, and our reporting software using a virtual environment. This technology allows for seamless continuity in the case of a disaster. We continue recommended tape back ups nightly as a fail safe for data recovery. We store the monthly tapes at an off-site location. We maintain a contract for a four hour response time for any component failure that supports our critical applications. Hardware and Peripherals: We followed eClinicalWorks recommendations regarding peripherals. Network computers continue to be upgraded to meet memory requirements; and the organization has initiated an annual capital plan for information technology upgrades, desktops upgrades, memory upgrades, etc. We continue to utilize computer mounting arms (Ergotron) that are mobile and ergonomically placed for the providers and nurses


in exam rooms and other locations. In 2009, we decided to upgrade to small USB printers in each of our exam rooms for improved efficiency for our staff and patients, eliminating the constant walk to a network printer in another location and the need to sort through multiple documents. Providers now print educational material right in the exam room and hand it to the patient without having to leave. Prescriptions can be printed or e-prescribed directly to the pharmacy for our patients. Scanners are located in front desks on each of the patient units. We have reduced the need to share tools such as scanners and camera in high volume areas for improved flow. In addition, directly connecting clinical tools into the EHR for patient safety, accuracy in documentation, and ease of reporting began in 2008 with the connection of Blood Pressure units, ECGs and spirometers. 8. Process: Implementation and Transition to EHR Strategy/Approach: Open Door's full scale implementation was comprehensive and successful due to a robust organizational culture geared toward productive adoption, and enhanced with clear communication and high performance interdisciplinary teams. Staff members were involved in planning for the implementation and kept apprised every step of the way through normal channels of communication. Updates and changes are also handled in this way today including at full staff, site, departmental and pod meetings as well as management and provider meetings that include supervisors, lead clinicians, and site based leaders. Our employee newsletter also provided a lot of information about the system to employees. Daren Wu, our Chief Medical Officer, prepared the provider staff and embraced the project so wholeheartedly, knowing that the EHR would improve the systems that always nagged providers (missing charts, unfilled lab reports, incomplete medication and problem lists, just to name a few), that he successfully engaged all, even the most computer phobic providers. The Director of Behavioral Health similarly set the stage for the therapists. Communication/transition: The reasons why our HIT system use is so robust include super-users who are deployed across the entire organization to coach, support feed-back and coordinate best practices. We continue to support communication about the system and upgrades through emails and the one page News Briefs produced twice a month since November 2008. Formal and informal training are a part of our strategic plan in 2010. Workflow: Open Door was well prepared for the needed workflow redesign since we had participated in many collaboratives, had redesigned the exam rooms to support technology, and had cross-trained staff to accommodate our chronic disease registry and improve our registration and check-out procedures. The changes resulting from the EHR implementation were relatively smooth since we were more than ready and enthusiastic about this strategic change. The Chief Medical Officer created most of the medical templates. Similarly, the Director of Behavioral Health created the mental health templates. This was done prior to go-live with input from the medical and mental health staff. The Director of Clinical Knowledge was aligned with these efforts and weighed in continually stressing the use of structured data so that we could extract useful information. Education/training/learning: There were virtually no obstacles to staff acceptance of eClinicalWorks and a good deal of enthusiasm preceded our go-live. However, some did better than others in the classroom and in their exam rooms. We went live on practice management first and believed that the enthusiasm of the support team would transfer to the providers when they followed on the EHR. Classroom training on the system happened in phases over a twelve week period. We were working off the test system, with a dummy database of patients that we were building to replicate conditions and patients at Open Door. Interdisciplinary super-users received comprehensive training first which allowed us to embark on the system set-up and test plan with the support of on-site eCW staff. The super-users then designed the training plan that would be delivered two weeks later by the eCW trainers to supervisors first, then a week later to teams of support and billing staff who would learn the practice management module in two Open Door classrooms; one in each of our two biggest sites. The phases were scheduled with enough time in between to prepare for the next round of training but not too much time that we would forget what we already learned. Supervisors and site managers scheduled their staff and were on hand to observe their learning. Each group had two full days of class room training spread out over several days. Most staff were scheduled in half day sessions to learn the key aspects of the system first, with time that followed to be back in their workstation for practice. We had a very firm cut away from our old system, and succeeded in going live at all sites in less than two weeks time.


A similar format was used six weeks later in preparation for the electronic health record roll-out. This time, interdisciplinary groups of providers and support staff were scheduled in half day classroom sessions with time back at their workstation to practice. The only difference was that once a provider returned from the classroom training, he/she was encouraged to use the EHR right away rather than document the visit on paper. Providers had half their usually scheduled patient volumes for a two week period, but we found most asked to return to full schedules in advance. Several locum tenens physicians were brought in to provide access to care during the reduced schedules. As a precaution, providers continued to use encounter forms in parallel to be sure we captured all charges and did not negatively impact cash flow while they were learning. Providers returned to their exam rooms and had access to clinical super-users to help. Direct observation of their electronic documentation took place remotely as well; eClinicalWorks super-users monitored the provider work and validated their competence and could send in remedial help if needed. During this period every meeting had an eClinicalWorks focus and demo on how to do things properly. We continued to use encounter forms for about a month. This meant that support staff still needed to post charges and we were not yet enjoying the full integration of the clinical and business aspects of eClinicalWorks. Still, the advantages of clinical care templates, e-prescribing, e-lab ordering and faxing referrals were huge and everyone caught on. Next, we turned our attention to eliminating paper encounter forms. For the benefits of the fully integrated product to light we needed to be sure audits and systems were in place to protect our revenue streams. Providers needed to complete their notes and identify proper procedure codes so that claims could be created and submitted on a timely basis. The CFO attended every site meeting, every provider meeting and nearly every pod meeting to be sure every one was doing it correctly. Open Door was live in 20 weeks from contract signing. Information exchange: The bi-directional interface with LabCorp, our reference lab, was in process soon after the departure of the eClinicalWorks trainers. Three years later when we changed laboratories we recognized that the new contractor, Bio-Reference, needed to have the interface in place by the time we transitioned. The new interface was operational by the go-live date, and while we had some minor initial challenges, this interface has been operational and allows us to track laboratory results. As we fully embraced the integrated eClinicalWorks product, it became time to focus on our practice intelligence capabilities; we needed financial and clinical reports to manage our practice and populations of patients. We could not access the clinical indicators we had formerly captured in our registry system, and the canned reports from eCW focused on practice management and financial parameters were not meeting our needs fully either. Since our goal of Management through Measurement was fully present throughout our implementation, we immediately began working with our BridgeIT software consultant to recreate the data warehouse we needed to produce operational, clinical, and financial reports that all at Open Door had come to rely on for analyzing our organizational goals and strategic objectives. Even with the sheer magnitude of files and data in the fully integrated eCW product, BridgeIT was an efficient repository that provided us with a tool for querying, data aggregation and analysis. Though there have been reporting upgrades by eCW with their Cognos product – EBO, Open Door continues to use the BridgeIT application because it is fully mapped, integrates clinical, financial and operation information in one report, and allows us to validate the eCW reports. Hardware/networks: With a clearly specified list of required hardware from eClinicalWorks, network checks prior to go-live and an on-going network testing program, our network performed well for the initial six months on eClinicalWorks. Although eClinicalWorks recommended upgraded Cisco switches to Gigabit speed at the time of our purchase, we reviewed our WAN traffic studies and determined that we had enough capacity for additional traffic and would wait. However, network traffic became an issue after nine months as the data in eClinicalWorks became more robust and we determined that an upgrade was in order. At that point we implemented Cisco SONA architecture with a core and access layers with Cisco Gigabit stackable switches and this improved access at the LAN level. Network monitoring continues to be a primary focus of our IT staff as our staff expectation is that our technology will always be promptly available. Historical Data: The super-user team had a lot of discussion about our data migration plan. We felt strongly that Medical Manager, our old practice management database, was a mess and the installation of eCW was our


opportunity to clean up our patient demographics. We decided that we would only migrate basic patient info such as name, address and phone number. We put insurance information into a note field and determined that the pain of re-registering every patient would be worth it in the long run. We had hoped to be able to migrate the clinical indicators captured in our PECS registry, but eventually concluded that our collective energy was better devoted to getting the lab interface fully up and running. Super-users supported our providers and clinical support staff in manually uploading our patient's social history, problems, immunizations, and medication lists. Document Management: Since we were re-registering every patient in eClinicalWorks, we determined that patient registration and consent forms needed to be scanned into the system along with income documentation or attestation forms as appropriate. We also scanned patient insurance cards and Medicaid eligibility print-outs from the State's EMedNY system. We took a digital picture of every patient and attached it to their registration screen. Specialty reports received following referral were scanned by our medical records department and attached to the patient's virtual record. While medical charts were still being delivered we decided that providers could flag contents to be scanned and included in the EHR. Paper medical records were delivered routinely for six months, and are now sent only when specifically requested by the provider or nurse. In fact, in 2009, we completely removed the paper charts from the record area in one of our locations, and plans for clinical expansion in our other sites include conversion of paper medical record rooms in 2010. Continuity of Care: The EHR was acquired to support continuity of care within the health center, across disciplines, and along the continuum of care. We are striving toward a medical home model where providers are responsible for a stable panel of patients whom they manage across the continuum of care. The practice management system provides tools to track who the primary care provider is when a patient calls in for an appointment. Physicians on call or rounding in the hospital can access patient records anytime through the Virtual Private Network (VPN). Obstetricians who deliver patients in the hospital are now able to access the ambulatory medical record in labor and delivery. When Open Door and its admitting hospitals are connected to the THINC RHIO for information exchange, continuity of care will be further enhanced. Support: Our super-users provided most of the initial support until our supervisors became totally proficient in eClinicalWorks. Today there are additional champions within each site who can offer on the spot technical assistance; many are proficient in both practice management and electronic systems. Our help desk is staffed by two IT support staff and is backed up by our business analyst who monitors and trends the requests for assistance coming in. Regular auditing occurs to assess compliance with appropriate registration, insurance or sliding fee scale set-up, claims creation and charge capture on the billing side. When errors are detected, site mangers or supervisors take them to the offending staff member for correction and additional training. Our approach of regular monitoring with feedback, correction and additional training when necessary continues today and allows us to continually look at improving our operations. Training on technology at Open Door is now part of the initial orientation for all new hires in order for us to succeed in our strategic objectives. Maintenance and Sustainability: We developed our IT infrastructure at Open Door over the course of several years through our technology partners such as – eClinicalWorks, Paetec, Carousel, along with the involvement of our competent technical staff, assistance from the Chief Information Officer of our managed care partner, Hudson Health Plan, and continuous education of the governance group through our primary care association, HIMSS, our vendor, and our auditors. Facility improvements in all of our sites from 2004 to 2006 enabled the technology backbone to be in place when we began our implementation. To maintain eCW’s high levels of performance, we monitor the speed of the network and have graphs of system traffic to be sure we have the capacity to handle our volume. We have found that sharing and comparing technical infrastructure with other health centers, participating with our HCNNY partners described earlier, and linking with other eCW users continues to be beneficial. In 2009, our updated information technology plan focused on staff, hardware, software, connectivity, communications, and security needs along with anticipated information exchanges through the RHIO, patient portals, and digital imaging. Open Door continues to see information technology as our foundation for the future, one we are committed to maintaining and strengthening.


9: Proof: Data Collection, Data Management, and Measurement Open Door had purchased the data extraction and report writing software “BridgeIT” in 2003 to write reports in our previous practice management system. This software allowed for ease of report writing and data analysis. Open Door’s management team soon became facile with the use of BridgeIT and developed performance improvement, operations and financial programs that were informed by data use and analysis. After the first few months of eCW implementation, the Management Team became eager to analyze the data, but found it difficult to retrieve using reports available in eCW. The reports did not answer our needs as written. We tried looking at the data tables and writing queries but the tables were designed for front end use and were very difficult to navigate. We missed the availability provided by our BridgeIT solution. The receipt of the ARHQ Grant “Evaluation of a CDSS and EMR-Based Registry to Improve Management of Hypertension in a Community Health Center” (Appendix 4) made the need for access to eCW data an imperative. This research grant required a monthly data extraction of over 42 discrete data elements on each adult medical encounter. These data elements included not just easily retrievable data such as race, ethnicity and provider but also calculated information such as “has the patient ever been diagnosed with Hypertension” or “when was his last lipid panel performed?” In the years of BridgeIT use prior to eCW, Open Door had developed a trusting relationship with a BridgeIT report writing consultant, Heckman Consulting. Heckman Consulting was willing to look at the possibility of using the BridgeIT tool to extract data from eCW for analysis and reports. This was an ominous task because of the multitudes of tables and individual fields in eCW. These fields and tables had to be extracted, identified, normalized, named and linked to each other. The ARHQ grant provided the support for Heckman Consulting along with Open Door staff to map the necessary eCW data and write the needed report. Twenty seven individual queries were eventually needed to create the report for the monthly data extract for the ARHQ project. Once the eCW fields needed for the hypertension initiative were mapped to BridgeIT it seemed only logical to continue and map all the eCW fields, and provide unrestricted access to the eCW data. It took a year and a half. Open Door clinical, financial and operations staff worked closely with Heckman Consulting to identify data fields and validate data. In the end, Open Door and Heckman Consulting had substantial knowledge about the data structure of the eCW software. The resulting product has become known as BridgeIT for eCW. The BridgeIT Software product is commercially available and the customized mapping to eCW is the intellectual property of Heckman Consulting. (Open Door has no financial incentive for the sale of BridgeIT or the BridgeIT for eCW software). Open Door staff have demonstrated BridgeIT for eCW for over 25 eCW community health center users and encouraged its use to assess eCW data for the needs of the center and for the meaningful use needs identified for 2011. BridgeIT for eCW is used every day at Open Door in three major capacities: Data Validation, Financial Analysis and Performance Improvement or making the data tell a story and work for us to improve care and efficiencies. The table below identifies some uses of the BridgeIT reports. BridgeIT Data Integrity/Validation Uses BridgeIT Financial Reporting Uses

• Dates entered into text fields that aren’t real dates. • Visits no showed or cancelled accidentally

resulting in a hidden progress note and no claim. • Immunizations ordered but not documented. • Patients without assigned Sliding Fee status. • In house labs without documented results. • Patients without an assigned Primary Care Giver.

• Monthly productivity reports covering all providers

• Monthly revenue reports • Monthly collections reports • Monthly payer mix reports • Monthly report on locked visits; visits

without claims

BridgeIT Performance Improvement Sample • Monthly report identifying patients who have had two blood pressures over 140/90 and no diagnosis of

Hypertension. • Monthly report identifying patients with an A1c >9 and no follow up visit. • Monthly report of children with a BMI Percentile >85% and no problem on the problem list. • Monthly report of Women >21 years of age who have not had a PAP Smear in the past 3 years.


• Provider Report Card including Blood Pressure control in Hypertensive patients by provider, A1c control in Diabetic patients by provider, HIV Testing by provider, Asthma control by provider, Cancer screening by provider.

• Patients seen for a medical visit but not by their Primary Care Giver by site and by provider. • Percent of Medical visits made with assigned Primary Care Provider.

Perhaps the most exciting use of BridgeIT for eCW is the Clinical Dashboard. The health center controlled network HCNNY purchased, customized, and installed BridgeIT for eCW for each eCW participating Health Center. This allowed for the extraction of clinical data to be compared across centers, including data for diabetes, hypertension, cancer screening, BMI smoking status, and self management by race, ethnicity, age and other demographics. The ability to compare clinical outcomes and processes across health centers is unique and exciting. Eventually this dashboard will be embedded into Cognos and available to all the participating HCNNY Health Centers for QA, PI and data analysis; a true collaboration among health centers for care improvement. Clinical Measurement: EHR implementation helped Open Door recognize the important benefit of capturing health information for 100% of a targeted population, not simply using a sample of cases. Analysis of patient and visit data for Diabetic and Hypertensive patients reveals that these patients make up 15% of our adult population but utilize 27% of visit volume. This data analysis validates our resource allocation. As a result of better tools with which to manage patients, more diabetic patients have been identified and tested and more diabetics have better control of their blood sugar. The percent of patients whose A1c is below 7 increased from 35% to 44%. The number of Hypertension patients identified has almost doubled and blood pressure control in hypertensive patients improved from 38% to 62%. This is a testament to the benefits of a fully integrated practice management and electronic health records system and unrestricted to data. (See Appendix 1 Clinical Outcomes) Because of our AHRQ funded hypertension study, we have closely examined workflow. We have looked at what happens in the visit and designed electronic prompts to focus providers on needed care for our hypertensive patients. Prompts must be appropriate and should not "tune staff out"; rather we want to design prompts that allow clinical staff to be appropriately responsive. (See Appendix 2 Hypertension Intervention Users Manual) We have designed reports to identify when data is missed such as blood pressure or BMI. We run these reports daily and give rapid provider and staff feedback to change behaviors. Follow-up for patients with abnormal cancer screenings are also much improved with eClinicalWorks. The size of the target population has vastly increased with improved data capture enabled by our EMR as compared with a manual registry. For mammograms and Pap smears, marked increases and improvements are seen. These improvements were attributed to embedded clinical decision support systems (CDSS) to identify preventive health needs of patients in for acute visits as well as the use of registries to identify patients who need to be brought into care. We continue to study how an EHR can enhance workflow and ensure that following clinical guidelines improve patient care. (See Appendix 1 & 4) ** As discussed in above, Open Door discovered after EHR implementation that we had significant report writing needs for driving both clinical and operational performance. A grant from the AHRQ to study CDSS related to caring for hypertensive patients required clinical data extracts for statistical analysis. This led to the use of the BridgeIt reporting application to extract, transform and load all of our data into a data repository for more extensive reporting purposes. Open Door’s leadership team uses the BridgeIt software system as an auditing tool to identify changes or inconsistencies in clinical or operational practice that may need to be addressed with staff. For example, a monthly report is run that identifies patients by provider who have had two Blood Pressures over 140/90 but no Diagnosis of Hypertension on the Problem list. This type of electronic surveillance is not used alone but in combination with clinical judgment to help the Medical Director identify clinicians that need additional support or mentoring. Below is a list of reports that are provided monthly to the Chief Medical Officer:

• Diabetic Patients with A1c>9 and no follow up • Hypertension patients with BP>140/90 and no follow up


• Patients with two BP>140/90 and no Diagnosis if Hypertension • Immunizations ordered but not documented (Daily) • Abnormal labs such as STD, INR, PAPS or cultures with no treatment • Depressed patients without follow up PHQ9 • Patients on Coumadin without INR • Patients with URI for whom Antibiotics were ordered • Patients with Hypertension or Diabetes who had medical visit not with their Primary Care Provider or Primary Care Giver.

In the BridgeIt for eClinicalWorks data definitions (meta data), 100% of the fields are available to the user. There are approximately 1600 data tables in the 8.0.100 eClinicalWorks database. There are many tables and data fields that have been deprecated and no longer contain current or useful data. As such, while BridgeIt maps 100% of the data, not all of the data tables are passed through to the user reporting system. A BridgeIt user has access to all of the currently active EMR and PMS data fields. Open Door currently has 14 BridgeIt users. Most people run a few reports that have been written for them by either our consultant or one of our “Super Users.” Maria Mazzotta our CFO is a super user and writes all our Financial Reports. Donna Goldbloom is our Business Analyst and a super user and writes reports for both practice management and clinical, as does super user Pam Ferrari the Director of PI and Clinical Information. Recently our HIV Director has started writing reports and we have a volunteer who is working on reports related to patient retention. The supervisor of our Patient Advocate program tracks patient advocate activity with BridgeIt. Open Door has hosted BridgeIt trainings for other health centers who use eCW and BridgeIt and freely exchanges reports with other health centers who use both eCW and BridgeIt. A health center in Florida noticed that there were immunizations in their system that were ordered but not documented, and developed a report to find them. That center notified Open Door and sent the report which Open Door pasted into BridgeIt and found that we had the same problem. Open Door has subsequently shared that report with three other health centers. As BridgeIt for eCW is more widely deployed to health centers using eClinicalWorks (currently there are ten community health centers and primary care associations using BridgeIt and we believe that number could grow to about 40), we are confident that this collaborative learning will be extremely beneficial at Open Door and well as within the health center sector. ** 10. Progress/Impact: Value, Outcomes and Lessons Learned Achievement of objectives: The major objectives identified for implementing eClinicalWorks were increasing efficiency for finding health information, improving provider productivity, and improving patient safety and outcomes. Health Information is readily available at the desktop on our EHR, but Open Door recognizes that information from other health organizations required for improved continuity of care is the next area to tackle for improved efficiency. This is the continuing effort for health information exchange with our RHIO. As for productivity, across our organization we have seen an increase of over 7% in the number of users annually since 2007, and an increase in visits of 20% since the EHR was implemented. (For additional impact see Appendix 5 – ROI Analysis). As for patient safety and outcome improvements, the Clinical Report Cards that we share regularly monitoring the entire patient population seen annually have provided the following information:

Clinical Improvement Highlights 2007 2008 2009 2010

• Visits with PCG 40% 45% 55% 55% • BP Control 38% 46% 57% 62% • Diabetics tested 60% 99% 99% 99% • Diabetics Identified 809 1042 1046 1023 • Diabetics Controlled 35% 35% 41% 44% • Breast Cancer Screen 21% 26% 40% 40% • Cervical Cancer Screen 21% 59% 66% 66% • Asthma Action Plans 2% 10% 32% 40%


Strategic Alignment: Open Door’s unified practice management and electronic health record system has been the critical success factor used to pursue our strategic priorities. It has given us the tools to deliver value to the community by achieving higher rates of planned care and improved health status cost effectively and efficiently. The use of the EHR supported our 2009 submission to NCQA for recognition as a Patient Centered Medical Home Level 3. This recognition challenges us to continually review appointment access, communication with our patients about the health, the efforts to increase patient involvement in their care through self management, and the monitoring of the health outcomes and population management. The EHR has improved tracking and recall of our patients, tying our growth in users to improved patient retention of our highly mobile patient base. Sharing information learned from our report cards of clinical, financial, and operational data allows the leadership and staff to identify areas for improvement. Data use continues to be an important element for management strategy. Critical Success Factors: There are several critical factors that contributed to our success. First was our stage of readiness, due in large measure to significant workflow changes made prior to implementation. The typical split between administrative and clinical work was blurred and collaboration continues. The use of the PECS and New York Immunization registries the year before were also key factors in our success; care teams were entering and using data and decision support tools at the point of care. Solid planning was also important for our super-users’ ability to lead, work well together, and make decisions on the spot when needed. Our organizational culture was and is comfortable with innovation and change and our staff was well up to the task of learning new processes. In 2009 we used this same approach with our application of NCQA Patient Centered Medical Home Level 3. Our Performance Improvement initiatives continue to rely on management through measurement across all divisions along with a focus on data validation necessary to ensure the quality of the information available to all. Technical Infrastructure Measurements: In 2009, besides the monitoring tools needed by our IT staff focusing on the communications traffic, the load balancing of the servers, and the functioning of each of the servers, Open Door’s IT staff recognized that continuous feedback from end users is very important. This communication has helped establish that improved provider productivity comes from increased memory – upgrades to the server memory, and the desktop memory. The ability to understand that Incident Reports showing a “crash” of the system on the first work day of every month meant month-end reports were now taking longer and were interfering with starting the new work day, led to corrective IT measures. The infrastructure continues to be an area of focus, and in 2010 redundancy, increased speed and disaster recovery are the focus. To this end the IT staff is working collaboratively with the national user group of eClinicalWorks, our health centered controlled network –HCNNY, our RHIO, and consultants to improve our critical “utility” – health information technology. Financial Impact: The implementation of the EHR was a major cost for the organization, but the benefits of this implementation have already been recognized. The organization has increased patient revenues for our managed care plans – by more promptly billing and receiving our wrap around payments, and increased incentives for clinical services performed. The ability to grow the number of patients served and the annual visits without increasing the medical record staff has been a benefit. In 2010, the paper medical records space in all our facilities will be reclaimed to expand patient access to services and improve patient flow. The implementation of the EHR has positioned Open Door to receive incentives from e-prescribing, NCQA recognition, and the possibility of meaningful use incentives coming in 2011. While the organization has recognized that on going capital investments will be needed to maintain and improve our health information technology, Open Door is continuing to look at our collaborations for ways to minimize and share these ongoing investments. Three years into implementation, we have recouped the initial investment through increased clinical performance incentives ($381,161 YTD), decreased medical records personnel ($216,644 YTD), and decreased printing costs ($81,943 YTD) alone. Going forward, on-going EHR upkeep and maintenance expenses are expected to be more than covered by these on-going benefits. A formal return on investment breakdown can be seen in Appendix 5. Lessons Learned: The decision to implement the full eCW system (practice management plus EMR) continues to prove strategic. The fully integrated product provides greater efficiency for the users and vastly improved data integrity for care quality. Interoperable lab information and e-prescribing have also been important in high quality care delivery and for patient follow-up. As we struggle to get our dental interface to work between eClinicalWorks and Dentrix, we appreciate the complexity involved in interfacing different systems.


Vision and leadership at the executive level was essential for rapid adoption and Open Door’s continuing ability to use eCW robustly to support both the Medical Home and Meaningful Use. The strategic decision to undertake the full mapping of eClinicalWorks to BridgeIt was highly important and allowed Open Door to have nearly total access to all of our data through a data warehouse that is repopulated using extract, transform, load (ETL) technology every night. This structure allowed for the creation of a data mart where standard reports reside as well as the ability for end users to write ad-hoc queries and reports whenever needed. The ability to write queries and generate reports is becoming more wide-spread among Open Door staff and provides a strong backdrop for a clearer understanding of processes, data capture and critical analysis of all aspects of our work. We recognize how essential access to data is for a health care organization to be efficient and effective. ** Open Door’s first Davies site visit in 2009 noted a strong EHR implementation as an organization, as well as the extensive knowledge and enthusiasm of the senior management in the robust use of EHR. Feedback from the visit alluded to a gap in that knowledge from the senior level to the front line staff. After critically processing this feedback, Open Door began an aggressive campaign to educate and engage staff on all levels about the wave of change in health care that the staff themselves were making possible on the ground level. Special full-staff meetings brought everyone from across the organization together so that everyone would be “talking the same language” about EHR implementation and use. This information was reinforced during regularly scheduled weekly and monthly provider and staff meetings. With the staff already engaging the EHR in meaningful ways, providing the greater context and sharing the enthusiasm for its potential was not difficult. The result was a fluid organization operating “on the same page” all the more ready to deliver 21st century health care to the disadvantaged and underserved. ** Next Steps: Open Door will be implementing the patient portal function in 2010. To prepare for this tool, the organization identified the need to capture patient email addresses more consistently. Most recently the portal committee developed an online user survey for our adult patients to complete indicating which tools available on the portable should be initiated first. We expect the portal to be available later this year. The use of eMessenger services for our patients is also being explored. This will involve improved integration of reminder calls or text messages for our patients, and eliminate the need to support another software program to do these reminders. 11. Practice: Other Aspects That Describe Your Story and Model Practice Initiatives Collaborations continue with our national and local primary care association, NACHC and CHCANYS, the network controlled health center organization HCNNY, the RHIO, our AHRQ hypertensive study, other certified Patient Centered Medical Homes, and our HEAL grant collaborators. In each instance, we remain focused on the future of utilizing health information technology to improve patient safety and health outcomes. At a recent NACHC conference in Open Door provided demonstrations of its BridgeIT reporting tool to leaders from Colorado, California, New Jersey, New York, Florida, Illinois, Indiana, and Virginia. Open Door firmly believes in “Passing it Forward,” the idea that sharing knowledge of EHRs and quality improvement ultimately enhances patient outcomes and makes all health centers work smarter. To this end, Open Door continues to regularly host health centers to demonstrate how eCW and BridgeIT are used at Open Door and to demonstrate how care and the patient experience have been transformed. We have seen the process of care change for the better thanks to EHR implementation, and the more health centers that know our story, how we did it, and how they can do it, the better off we are as a community of health care centers committed to the underserved.

Davies CHO Award Application Open Door Family Medical Center, Inc. 2010 Nicholas E. Davies Award of Excellence Community Health Organizations

APPENDICES

TABLE OF CONTENTS

Appendix 1 - Clinical Outcomes (Page 1) A. Assigning Primary Care Givers B. Blood Pressure C. Diabetes D. Asthma E. Cancer Screening F. Clinical Outcomes Summary

Appendix 2 - Hypertension Intervention User’s Manual (Page 8)

A. Vital Signs B. Template C. Order Sets D. Clinical Decision Support System

Appendix 3 - Information Technology Network Configuration Maps (Page 19) Appendix 4 - Overview of AHRQ Grant: The Evaluation of a Clinical Decision

Support System and EMR-Based Registry to Improve Management of Hypertension in a Community Health Center (Page 20)

Appendix 5 - Return on Investment Analysis (Page 23)

A. Average Visits per FTE B. Days in A/R C. Average Collection per Visit D. Pay for Performance Incentives E. Decrease in Expenses F. Annual Benefit Flow

Appendix 1: Clinical Outcomes A: Assigning Primary Care Givers The first step towards Patient Centered Medical Home certification and the basis for Open Door’s clinical outcome program is establishing a patient’s personal relationship with a primary care giver. This allows all clinical data elements to be tracked back to the primary care giver and his or her team. In 2009 Open Door’s primary performance improvement project was to ensure that every primary care patient was associated with a primary care giver and that patients were indeed seen by that primary care giver. Below is the 2009 improvement in assigning patients.

Percent of patients in denominator who have seen their assigned PCG at least once in the last 12 months.

59.26% 59.37% 59.69%62.05%

71.03% 71.89% 72%74%

76.18%74.43% 74.67%

79.79%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

January February March April May June July August Sept Oct Nov Dec The graph below was created from data extracted from eCW using BridgeIt as part of our NCQA Medical Home application process. The monthly report below identifies patients month to month who have visits with their primary care giver and we give feed back reports to providers and site managers to aide in improving this metric. This report also validates the provider report card.

Medical Home Visits with Primary Care Giver

0

20000

40000

60000

80000

100000

120000

Visits not with PCG 24473 52189 47843

Visits with PCG 16584 41941 58243

Total Visits 41057 94130 105726

Percent with PCG 40% 45% 55%

2007 2008 2009

All provider feedback reports are based on the imperative that patients are seen by their primary care giver whenever possible. Reviewing provider panels and access to care reports are essential to ensuring accurate clinical metrics.

Open Door Family Medical Center, Inc. 2010 Davies CHO Award Application 1

Appendix 1. A.

Improvements in clinical care outcome measures for the organization have been profound in the areas of diabetes and hypertension. These outcome measures are also analyzed by site and by provider to look for areas for focused improvements and interventions. B: Blood Pressure Below is a graph showing the blood pressure improvement over the past three years of using eCW. Through our ARHQ grant we have focused a great deal of attention on hypertension and devoted time and resources to ensuring that all the available clinical decision support available is used. See Appendix 2 for the Hypertension Intervention Users Manual.

0.00%

20.00%

40.00%

60.00%

80.00%

Improvement in Blood Pressure Control

3.89% 1.24% 2.56% 1.40%Controlled 38.33% 45.76% 56.58% 62.09%

Not Controlled 57.78% 52.65% 40.42% 36.17%

Not RecordedProperly

0.00% 0.35% 0.44% 0.35%

2007 2008 2009 2010

Not Recorded

Hypertension outcomes are provided to providers also so that they can compare themselves to their peers. The following report was creating using BridgeIt and eCW data. Visit since report year Yes Facility (All) HT Y SMGoalCurrent (All) race (All) Ethnicity (All) Diab (All) Over40 (All) Pat Count % BPStatus

PCGProvName Controlled Not Controlled Not Recorded Properly

Grand Total

Arraiano, Nicole 64.41% 35.59% 0.00% 100.00%


Appendix 1. A. & B.

Begum, Noor 60.00% 38.57% 1.43% 100.00%Caamano, Leo 55.84% 44.16% 0.00% 100.00%Cohen, Asaf 73.10% 26.90% 0.00% 100.00%Meyer, Patricia 62.13% 37.02% 0.85% 100.00%Moysak, Jane 59.62% 40.38% 0.00% 100.00%Pozzuoli, Monica 100.00% 0.00% 0.00% 100.00%Puthiyamadam, Mary Rose 66.56% 32.81% 0.63% 100.00%Rajan, Anil 55.77% 43.27% 0.96% 100.00%Rovito, Lucy 72.87% 26.32% 0.81% 100.00%Steinberg, Sarah 52.22% 47.78% 0.00% 100.00%Wu, Daren 66.11% 33.89% 0.00% 100.00%Yuen, Thomas 52.11% 47.64% 0.25% 100.00%Zeppieri, Matthew 58.59% 41.41% 0.00% 100.00%Grand Total 61.51% 38.11% 0.38% 100.00%

C. Diabetes Improvement for our diabetics since the implementation of eCW has also been dramatic. The use of templates, order sets and clinical decision support systems learned through the ARHQ grant process for Hypertension was applied to diabetes with similar results. More patients were identified, more patients were tested, and more patients were controlled.

Diabetic Identification, testing and control over time

0

500

1000

1500

Diabetics Controlled 188 170 365 427 452Diabetics Tested 536 485 1038 1040 1018Diabetics Identified 662 809 1042 1046 1023

2006 2007 2008 2009 2010

Implementation AfterBefore


Appendix 1. B. & C.

Below is an example of the clinical decision support system that Open Door has configured to prompt providers for diabetic care. These prompts encourage both testing and medical management.

D. Asthma Increased use of Asthma Action Plans has improved Asthma Care for some of our most vulnerable children.


Appendix 1. C. & D.

Having an imbedded Asthma Action Plan and a process to encourage its use has significantly improved asthma care at Open Door. The Hudson Valley Asthma Coalition has commended Open Door for the design of this Asthma Action Plan and its use at Open Door.

Percent of Patients with asthma with a current Asthma Action Plan

2%10%

32%40%

0%

10%

20%

30%

40%

50%

2007 2008 2009 2010

ECW’s clinical decision support alerts providers to assess Asthmatic patients for symptoms and control.

E. Cancer Screening Cancer screening for both cervical and breast cancer has increased with the use of clinical decision support systems at the point of care, the use of the registries to identify patients who need care, and employing outreach to get these patients into care.

Cervical Cancer Screening in Women over 21 years

63%

21%

59%68%

0%

20%

40%

60%

80%

2006 2007 2008 2009

It took 3 years of screening to improve this 3 year measure


Appendix 1. D. & E.

Breast Cancer Screening

2386 2600

3576

5469

358 546945

2195

5 18 25 240

1000

2000

3000

4000

5000

6000

2006 2007 2008 2009

WomenScreeningscancer Identified

The clinical decision support system that prompts providers to order cancer screenings is displayed below.


Appendix 1. E.

F. Clinical Outcomes Summary A summary of improved clinical outcomes since EHR implementation in 2007:

Open Door Outcomes

0%

20%

40%

60%

80%

100%

120%

· Visits withPCG

· BP Control · Diabeticstested

· DiabeticsControlled

· BreastCancer Screen

· CervicalCancer Screen

· AsthmaAction Plans

2007200820092010


Appendix 1. F.

Open Door Family Health Center, Inc. Managing the Hypertensive Patient – User’s Manual

v 1.0 1 March 2009

This User’s Manual explains the eCW Version 8.0 enhancements that provide Clinical Decision Support for the management of Hypertensive patients. Specifically, it includes instructions on the use of: Topic Section

Vital Signs ........................................................................................................................................ 1.0

The Hypertension Template ............................................................................................................. 2.0

Hypertension Order Set ................................................................................................................... 3.0

Clinical Decision Support System (CDSS) ......................................................................................... 4.0

8Appendix 2

Open Door Family Medical Centers, Inc. Managing the Hypertensive Patient – User’s Manual

v 1.0 2 March 2009

1.0 VITAL SIGNS Recording Blood Pressure. The blood pressure field contains logic to prevent the entry of an invalid Blood Pressure (BP). It also flags the user if the BP is out-of-range (inappropriately high). If an invalid or out-of-range BP is entered, ECW will display an error message.

Elevated BPs are displayed in red. In eCW, elevated is defined as > 140 systolic or > 90 diastolic. (Note that diabetic patients should be controlled below 130/80.)

Appendix 2. A. 9


v 1.0 3 March 2009

2.0 HYPERTENSION TEMPLATE 2.1 HPI and Examination. If the BP is elevated due to hypertension, you may choose to use the Hypertension Template to conduct the recommended HPI and examination. Use of the Hypertension Template will facilitate documentation of the recommended elements of the HPI and examination of the hypertensive patient. To access the template: • go to the template button at the bottom of the progress note and choose “-Hypertension” from

the list of generic templates • merge this template into your progress note. It is recommended that you add this template to your favorites list. Note that the Open Door Hypertension Order Set is associated with the Hypertension Template.

Appendix 2. B. 10


v 1.0 4 March 2009

2.2 Adding Hypertension to the Problem List. When an ICD9 code for hypertension is selected under assessment, hypertension is added automatically to the Problem List. (This is true for the ICD9s for any chronic disease.)

2.1.2 Medication Compliance. For each patient medication, the template includes a form to capture compliance.

Appendix 2. B. 11


v 1.0 5 March 2009

3. ORDER SETS Just as the template brings in recommendations for HPI and examination, the order set provides recommendations for treatment and management of hypertensive patients. The order set is pre-loaded with medication, diagnostic testing, education and other elements related to hypertension. 3.1 Accessing Order Sets. There are three ways to access Order Sets: 1. Using the red button OS on the treatment screen. 2. Using My Favorite Order Sets on the side bar 3. Using the template-associated Order Sets from the side bar

1. Once hypertension is on the problem list from the current or any previous visit, the OS button appears in red alerting you that there is an order set available for this diagnosis.

2. If you designate an order set as a favorite, it will always be available on your right hand side bar. 3. If you use the hypertension template, the order set will be available on the side bar.

Appendix 2. C. 12


v 1.0 6 March 2009

3.2 Associating an Order Set

No matter which method you use to access the order set, you must associate it with a diagnosis. You should always pick Hypertension if using the Hypertension Order Set.

Once you link the order set to a diagnosis, the Order Set window will open. Look to be sure you have

the “OD- Hypertension

Order Set” If not, choose it from list.

3.3 Medication Management and Order Sets. The order set supports compliance with guidelines by presenting the user with recommended medications. Only Open Door recommended medications, based on JNC7 guidelines, appear in the Order Set. To order medication, click the box to the left. Note that the strength, frequency, and other details of the prescription can be modified. If the patient is already on a medication, the date it was ordered will be displayed.

Appendix 2. C. 13


v 1.0 7 March 2009

3.4 Using Order Sets to Order Tests and Services. Open Door’s recommended treatment standards for hypertension appear as pre-entered: • Laboratory Tests • Diagnostic Imaging

Tests • Immunizations • Lifestyle

Assessments* • Appointments Standard of care items that have already been done and are not yet overdue are grayed out. *Recommended assessments for elevated BMI and tobacco use appear as smart forms and are discussed more fully below under CDSS.

Notice that is recommended that all hypertensive patients receive appointments with nutrition for education in the dash Diet and with the patient Advocates for Self Management Support

Appendix 2. C. 14


v 1.0 8 March 2009

To order tests or schedule appointments • click on the

appropriate check box(es)

• carefully review your orders to see that the dosage and frequency are exactly what you want

• click ‘order’ at the top. • You can document

patient refusal or contraindication.

Everything that you choose from the order set will be added to your progress note automatically. 3.5 Educational and Reference Information. The order set contains on-line access to JNC-7 guidelines and patient handouts. Patient hand-outs can be printed direclty from here. When you check off and print educational materials, the documentation is automatcially inserted into your progress note.

Appendix 2. C. 15


v 1.0 9 March 2009

4.0 CLINICAL DECISION SUPPORT SYSTEM (CDSS) The Clinical Decision Support System (CDSS) tool assesses compliance with guidelines for the patient based on his/her age, sex, and medical history. CDSS includes Hypertension, Diabetes, cancer screening and preventive guidelines. 4.1 Using Clinical Decision Support. Use CDSS to learn whether the patient is due for any screening tests or preventive care based on his/her age or sex, or requires treatment for a chronic disease. You can order things you have forgotten or complete documentation that might be recommended using this tool.

To access the CDSS tool, click on the CDSS button at the bottom of the check out page.

Appendix 2. D. 16


v 1.0 10 March 2009

A screen appears listing guidelines in red when they are not satisfied (“non-compliant”), or green when they are satisfied (“compliant”). When a standard is addressed but not yet satisfied it is “snoozed”. For example, this patient’s BP control standard is “snoozed” because the provider has already intervened to control the BP. Also notice that this patient needs to have his smoking status assessed. It can be done from here.

Appendix 2. D. 17


v 1.0 11 March 2009

4.2 Smart Forms. Smart forms are electronic questionnaires that contain logic that facilitate

assessments. In eCW, tobacco assessments appear in a smart form.

To assess a patient’s tobacco use, • Click the down arrow next to “other

actions” • The tobacco control smart form

appears • Complete the smart form based on the

patient’s information • If the patient is a smoker, the form

automatically offers the Smoking Cessation Order Set and allows you to order appropriate meds and/or fill out the Fax-to-Quit Form.

Completion of the tobacco control smart form and/or the Fax-to-Quit form is automatically inserted into the patient’s history.

Once the tobacco assessment is completed, the smoking status and smoking cessation measures are reported as compliant.

Appendix 2. D. 18

Appendix 3 - Information Technology Network Configuration Maps 2008 Configuration:

Network Based Firewall

Access at all Sites:Multiple Circuits

orMPLS+Internet

Internet

Port Chester

Ossining

Mt. Kisco

PAETEC

Church St.

Sleepy Hollow

Open Door Family Medical

Open Door Family Medical

2010 Configuration


Appendix 3

Appendix 4 – Overview of AHRQ Grant: The Evaluation of a Clinical Decision Support System and EMR-Based Registry to Improve Management of Hypertension in a Community Health Center

This Agency for Healthcare Research and Quality (AHRQ) funded study is aimed at evaluating how the clinician use of clinical information tools affects their efficacy in improving the quality of care. The two specific aims of the study are to:

1) determine whether the use of decision supports and disease registries as part of electronic medical records (EMR) enhances feedback to providers and thereby improves hypertension control, as compared to the use of the EMR alone, and 2) identify implementation factors that influence the adoption of quality improvement interventions supported by the EMR.

This project is a collaboration among the Primary Care Development Corporation (PCDC), New York University (NYU), Columbia University, and Open Door Family Medical Centers. PCDC, the lead agency, coordinated the development and implementation of the system and process changes, as well as staff preparation and training. NYU and Columbia lead the research design and analysis, and Open Door co-leads the development of the intervention and serves as the clinical site. The study entails customizing the EMR to include hypertension-related functionality, incorporating the tools in Open Door’s operation, collecting baseline data and intervention data (both from the EMR and through focus groups and surveys), and conducting data analysis. Examples of data to being evaluated include:

Clinical Effectiveness Implementation Factors Blood pressure % of clinicians using tools % of patients with BP checks in last 6 mos;

12 months Clinician satisfaction with tool

Hypertension medication Barriers and facilitators to use Referrals to nutritionist Clinician attitudes towards

hypertension guidelines

As part of this project the study group participates in AHRQ-sponsored annual forums, develops a dissemination plan should the intervention found to be effective, and will publish the findings of the study. Estimated Timeline: This is a three-year study (Oct 2007 – Sep 2010) with an implementation timeline estimated as follows: Study Year Dates Projected Activities

1 Oct 07 – Sep 08 • Obtain IRB Approval • Collect Baseline Data • Develop Intervention

2 Oct 08 – Sep 09 • Test and Train on Intervention • Implement Intervention (includes adoption period) • Collect Post-Intervention Data

3 Oct 09 – Sep 10 • Continued post-intervention data collection • Data Analysis • Final Report and Dissemination Plan


Appendix 4

Baseline data:

Patients:

• 72% Hispanic

• 66% Female

• 90% at or below 150% of poverty level

Preliminary Baselines

• 94% screened for hypertension

• 16% reported with hypertension

Blood Pressure Control among Hypertensives:

• 18.5% were not controlled at any visit

• 54% controlled at some visit

• 27.5% controlled at all visits

Provider Attitude Towards Guidelines:


Appendix 4

Provider satisfaction with eCW:

Post-implementation data analysis will be made available September 2010, however preliminary improvements and benefits are catalogued in Appendix 1 Clinical Outcomes.


Appendix 4

Appendix 5 – Return on Investment Analysis Examined: Visits per FTE; Days in Accounts Receivable; Average Collection per Visit; Pay for Performance Incentives; Operation Expenses Directly Effected by EHR; Annual Benefit Flow Three years into implementation, Open Door has recouped the initial Electronic Health Record investment through increased clinical performance incentives ($381,161 YTD), decreased medical records personnel ($216,644 YTD), and decreased printing costs ($81,943 YTD) alone. Efficiencies guaranteed by the EHR, including prompt billing, improved workflow and provider productivity, have also led to increased visits per FTE, decreased days in AR, and increased collections per visit. A: Average Visits per FTE After a slight dip the year of the implementation (2007) due to set up and staff education delays, average visits per FTE increased over 10% from 3,207 in 2007 to 3,585 in 2009.

Average Visits per FTE

3,000

3,100

3,200

3,300

3,400

3,500

3,600

3,700

2006 2007 2008 2009

Visits

per

FTE

B: Days in A/R Set up and staff education delays also effected Days in AR the year of implementation, but declines are demonstrated thereafter.

Days in A/R

0

10

20

30

40

50

2006 2007 2008 2009

Num

ber o

f Day

s


Appendix 5. A. & B.

C: Average Collection per Visit Average Collection per Visit saw sustained increases immediately.

Avg Collection per Visit

$0

$25

$50

$75

$100

$125

$150

2006 2007 2008 2009

Avg

Col

lect

ion

per V

isit

D: Pay for Performance Incentives Improved capture of data and clinical decision support systems in the EHR allowed for better clinical outcomes which in turn led to increases in pay for performance incentive payments from Open Door’s managed care plans.

Pay for Performance Incentives

$100

$150

$200

$250

$300

$350

$400

2006 2007 2008 2009

in T

hous

ands


Appendix 5. C. & D.

E. Decrease in Expenses Personnel expenses saw immediate decreases after implementation due to decreases in the medical records staff. As paper charts became less relevant, headcount for medical records staff continued to decrease. Printing/paper costs saw an increase the year of implementation due to initial set-up and back-up requirements, but have steadily decreased since.

Decrease in Expenses

$0

$50

$100

$150

$200

$250

2006 2007 2008 2009

in T

houn

sand

s

Personnel Cost Printing Costs F. Annual Benefit Flow The Annual Benefit Flow shows Open Door breaking even after three years of EHR implementation. Additional savings going forward are reasonably expected due to steady or decreasing maintenance costs, and steady or increasing benefits from decreased staff, printing/paper costs, and increased pay for performance incentives.

Annual Benefit Flow

-$600

-$400

-$200

$0

$200

$400

$600

$800

2007 2008 2009in T

hous

ands

Annual Benefit due to EHRIncremental EHR Costs (One-time and Ongoing)Cumulative Net Flow (ROI)


Appendix 5. E. & F.

Last Medical Visit Dashboard Health Center: Ovul8.': Diabetic.': HT?:

Hypertension P""""lonee BP Status Hypertelllion Smoking Status Hypert ....ion HT BPStalus SmokeStatus

• Nol Recorded Property • never_moker r~"""""""'~ Not Controlled former smoIlM'

.Yes No ......~.'~ • Con_ • cunwnt amoker

J..L: (bIaink) (bIonk)No

83.9% never ... ... ·+-1 (blank) 5.4%90.8 former ... 1.9%

current s... 44.8% Not ConlrOliod

2.0%

Diabetes Control Diabetes BP Control Dlab LaatA1CStatua BPStatusDM

.Yes . Undef'7

ot ...

• Not Recorded ProporIyOvo<. Not ControlledNo • Between 7 and g Cont"'''e. (blank) (bIonk)

(blank) 65.7'l'.

J.~

NOl Controlled n .2%

- --

BP Status Hypertension Health Centers : Over 18?: Diabetic?: HT7: Sh_ Data?:

WestsideHudson Rlwr BPSt.lu. BPStatuIBPStatul

• Not Recorded Property Net Contron.d

• Not Recorded Property • Hol RKOnlad Propao1y Not Controlled Hol controll...

2~-_~·-2J • Controlled • Control~d • ControlJed ,="=-J..':~ (bI.nk) (blank) (bI.nk)

, ~ .

Not Controlled NOIControlled "3 .0% 4O.A%

NOIControlled 60.1%

BpStatus ~ percentage BPStatus I ~ percentage BpStatys ~ percentage I

Not Recorded Properly 44 0.1% Not Recorded Properly 73 I 0.2% Not Recorded Properly 19 ' 0.1%

Not Controlled 16,6~ 1__43.0% I Nol ControlieiL 12,412 40.4% Not Controlled 8,179 1 60.1%

Controlled 20,189 ' 52.3% Controlled 17,503 56.9% Controlled 5,102 37.5~

!.tlli!n!si 1,764 4.6% !l2ImllU I 768 2.5% 309 2.3%~ Summary 38,623 100.0% Summary 30,756 Summary 13,609 100.0%100.0% ----=---------'------

__

Diabetes Control Ht!a/tlr CmTt!rs : 0wI'18?: Dfabt!Tic?: HT7: Slrow Data?:

Hudson RiYer LaslA1CStatus

• Under 7 Over 9

• Between 7 and 9 fblank)

Open Door LastA1CStatus

• Under7 Over 9

• Between 7 and 9 (blank)

Wt!stslde LastA1CSt.tu s

• Under 7 Over 9

• Between 7 and 9 (blank)

percentageLastA1 CStatys k2Yn1 ~ 4,931 36.6%

~

Between 7 and 9

!.b!.<ill!0 Summary

2,140 15.9%---1--------< 4,282 31.8%

2,112 15.7% '

13,465 100.0%

LastA1CStatys ~ IPercentage

Under 7 ( 4,633 44.8%

, ~I 1, ~ 17.8% 1 I Between 7 an ~ 3,~24 3..4 .1,70

!!lli!n.!U 1 336 I 3.3%

Summary 10,337 100.0%

LastA1 CStatus ~ percentage

Under 7 1,615 1 33.0%

I-Be

Over 9 =~===....l

lween 7 and 9

814 ~

1,3861

16.6% r

28.3%

- !!lli!n.!U 1,077 1 22.0%

Summary 4,892 100.0%

Diabetes Prevelance Health Centers: DiaJ¥ticJ: HT;>:

Hudson Riwr Westside Dlab Diab otab

• Yes • Yes • Yes No No No

No 84.1% No

No so.7"Io

89 .9%

I L

.QiilIl ~ percentage .D..iilh ~ percentage I2im ~ Percentage ~ 21,110 15.9% Y.§ 15,734 10.1% Yes 6,445 1 19.3%

~ 111,556 84.1% 139,285 NQ 89.9% ~ 26,978 80.7%

Summary 132,666 100.0% Summary 155,019 100.0% Summary 33,423 100.0%

. - -~.-

Provider/Measure Total CA NA BN LC EC AC PD JG DG AG

#Diabetics 531 3 21 29 30 8 56 32 2 13 10

# Al c in past year 522 3 20 26 30 8 55 31 1 12 10

% with Alc 96% 100% 95% 90% 100% 100% 98% 97% 50% 92% 100%

# Alc <7 253 3 11 11 15 4 17 16 3 3

%Alc <7 48% 100% 52% 38% 50% 50% 30% 50% 0% 23% 30%

#A 1c between 7 and 9 181 7 10 5 1 22 10 9 4

%between 7 and 9 34% 0% 33% 34% 17% 13% 39% 31% 0% 69% 40%

#Alc >9 9800% 200% 500% 1000% 100% 1600% 500% 100% 300%

%>9 18% 0% 10% 17% 33% 13% 29% 16% 50% 0% 30%

# Lipid

% Lipid 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

# Microalbumin

% Microalbumin 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

# DM BP<130/80 217 1 10 17 15 3 31 13 1 4 3

% OM! HTN with BP Controlled <130/80 41% 33% 48% 59% 50% 38% 55% 41% 50% 31% 30%

# Asthmatics 585 3 11 13 25 12 20 9 20 10 1

# with AAP 280 0 1 1 6 5 3 3 13 3 0

% with AAP 48% 0% 9% 8% 24% 42% 15% 33% 65% 30% 0%

# Asthma assessed control 127 0 8 2 12 7 11 4 17 7 0

# who's Asthma is well controlled 87 0 3 1 6 5 7 3 16 7 0

% who's asthma is well controlled 69% #DIV/OI 38% 50% 50% 71% 64% 75% 94% 100% #DIV/OI

Medication 94% 50% 93% 100% 100% 100% 96% 75% 64% 80% 100%

# eligible for PAP>21 2886 417 346 188 224 210 312 219 41 127 54

# with PAP 1948 366 277 122 130 120 182 126 10 98 9

% with PAP in 3 years 67% 88% 80% 65% 58% 57% 58% 58% 24% 77% 17%

# eligible for Breast Cancer Screen 2668 107 99 124 80 60 133 82 1 65 33

# mamma performed 1196 45 44 52 34 24 55 31 1 34 5

% with mammogram 45% 42% 44% 42% 43% 40% 41% 38% 100% 52% 15%

# Hyperte nsives No OM 1172 15 29 54 69 24 89 33 12 23 15

# Controlled <140/90 742 13 21 35 40 19 66 20 6 18 9

<140/90 63% 87% 72% 65% 58% 79% 74% 61% 50% 78% 60%

Pts 18 to 64 with visit 13199 626 606 226 620 386 671 415 145 249 116

HIV Tests 4204 295 264 58 219 58 127 120 32 78 35

% HIV Tested EVERII! 32% 47% 44% 26% 35% 15% 19% 29% 22% 31% 30%

Depression Screening Num 13573 615 605 223 623 379 688 413 140 245 123

Depression screening Den 1928 72 109 27 87 84 72 37 77 26 35

Depression screening % 14% 12% 18% 12% 14% 22% 10% 9% 55% 11% 28%

Unlocked Notes 2090 355 32 104 34 8 49 22 14 23 36

RX eprescribed 48% 24% 6% 80% 50% 23% 11% 5% 91% 79% 80%

% of visits PCG 54% 38% 37% 40% 43% 45% 59% 30% 88% 53% 1%

Patients >50 4886 87 106 115 196 86 246 123 117 50

# Screened 1310 21 33 28 48 20 87 36 17 31

% Screened Colon Cancer 27% 24% 31% 24% 24% 23% 35% 29% #DIV/OI 15% 62%

Documents

Open Door Family Medical Center, Inc. - himss