Research 101:Primary Care Research

and OCHIN’s Practice-Based Research Network

Sonja Likumahuwa, MID, MPH OCHIN PBRN Coordinator

OCHIN Learning Forum November 15, 2012

Overview

• OCHIN Data Challenge!• What is research? • About OCHIN – what makes OCHIN unique for

research?• About practice-based research• Learning from YOU!

The OCHIN Data Challenge

1. OCHIN members

How many active member organizations does OCHIN now have on Epic (i.e., live on the system)?

a.63b.57c.35d.99e.None of the above

1. OCHIN members

How many active member organizations does OCHIN now have (i.e., live on the system)?

a.63 (with 310 clinics and 446 departments – 68 orgs signed)b.57c.35d.99e.None of the above

2. Total patients

How many distinct patients with one or more visits are in the OCHIN database (through 9/30/2012)?

a.490,398b.885,863c.1,221,597d.1,807,3789e.None of the abovef.All of the above

2. Total patients

How many distinct patients with one or more visits are in the OCHIN Epic database (through 9/30/2011)?

a.490,398b.885,863c.1.2 million (with 11 million visits).   d.1,807,3789e.None of the abovef.All of the above

3. Total patients in past year

How many distinct patients were seen in OCHIN Epic member clinics in the past year (10/1/2011 - 9/30/2012)?

a.350,823b.539,366c.778,340d.999,999,992e.None of the above

3. Total patients in past year

How many distinct patients were seen in OCHIN member clinics in the past year (10/1/2011 - 9/30/2012)?

a.350,823b.539K patients seen in past year (with 2.2m visits)c.778,340d.999,999,992e.None of the above

4. Diabetics

What percentage of all patients seen in OCHIN clinics with Epic EMR have a recorded diagnosis of diabetes?

a.6.1%b.2.7%c.8.6%d.50%e.None of the above

4. Diabetics

What percentage of all patients seen in OCHIN clinics with Epic EMR have a recorded diagnosis of diabetes?

a.6.1% b.2.7%c.8.6%d.50%e.None of the above

5. Race

What percentage of patients in the OCHIN database have a recorded race?

a.5%b.21%c.85%d.95%e.None of the above

5. Race

What percentage of patients in the OCHIN database have a recorded race?

a.5%b.21%c.85%d.95%e.None of the above

6. Payor mix

What percentage of patients in the OCHIN database were self-pay at their last visit?

a.21%b.32%c.50%d.75%e.None of the above

6. Payor mix

What percentage patients in the OCHIN database were self-pay at their last visit?

a.21%b.32%c.50%d.75%e.None of the above – 41% (40% were Medicaid)

7. Tobacco use

What percentage of patients in the OCHIN database have documented tobacco use ( > 12 yo)?

a.15%b.19%c.23%d.28%

7. Tobacco use

What percentage of patients in the OCHIN database have documented tobacco use ( > 12 yo)?

a.15%b.19%c.23%d.28%

Anybody surprised by the data?

What questions did the data raise for you?

What is Research?

A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.

Research and QI – what’s the connection?

• QI: small-scale, unknown applicability to other settings.

• Research: generalizable to other settings• QI becomes research when you start thinking:

– “I want to test to find out why this QI intervention was/wasn’t successful.”

– “I wonder if our successful QI initiative would work in another

clinic/department?”

OCHIN• Formed in 2001 with $2 million grant from HRSA• 501c(3) collaborative• Community Health Center-Controlled Network• Organized Health Care Arrangement• State-of-the-art electronic clinical record-keeping in

safety net clinics • Hosted platform using Epic Systems, Inc. – linked across

all clinic sites• Grown to $20 million national collaborative• Members: FQHCs, FQHC look-alikes, rural and school-

based health centers

OCHIN

• 65 member organizations, 11 states • Over 300 individual clinics• Over 3000 providers• 1 million patients, 2.1 million annual visits• Provides economies of scale for high-quality

health information technology products

Serving the Safety Net

• Federally Qualified Health Centers (FQHC)• School-based Health Centers• Nonprofit Community Health Centers• County and Public Health Departments• Rural Health Centers• Mobile Health Centers• Field-based Migrant Health Clinics• Homeless Clinics

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Where We Are

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Diverse Patient Population (n=1.2 million patients) July 1, 2002 – September 30, 2012

Sex EthnicityFemale 55% Hispanic 27%Male 45% Non-Hispanic 61%Women & Children 74% Not Collected/Unknown 12%

Federal Poverty Line Race100% and below 55% American Indian 1%101% - 150% 9% Asian 3%151% - 200% 4% Black 8%Over 200% 12% White 72%Unknown 21% Not Collected/Unknown 15%

Other 1%Visits by PayorCommercial 12%Medicaid 40% Patients: 1,221,597 Medicare 7% Visits: 11,664,224Other 1%Self-pay 41%Unknown 0%

OCHIN’s Research Potential

• Master Patient Index (one record across the network)

• Large, diverse patient population• Linked data that’s easy to query (back-end)• Patient continuity in the network• Hard-to-reach patients (uninsured, poor,

migrant, homeless, women and children)

OCHIN Safety Net PBRN

• OCHIN is the founding member and administrative home to a PBRN that is focused on the safety net

• The OCHIN PBRN is an AHRQ-registered primary care research network

• Works together with COG and Data Stewardship Committee to oversee research at OCHIN

PBRN Definition

A group of practices devoted principally to the primary care of patients, and affiliated in their mission to

– Investigate questions related to community-based practice

– Improve the quality of primary care

• Ongoing commitment to network activities

• Linking practicing clinicians with investigators

• Working to enhance the skills of network members

http://www.ahrq.gov/research/pbrn/pbrnfact.htm

1000 persons

800 report symptoms

327 consider seeking medical care

217 visit a physician’s office (113 visit a primary care physician’s

office) PBRN Research

65 visit a complementary or alternative medical care provider

21 visit a hospital outpatient clinic

14 receive home health care

13 visit an emergency dept

8 are hospitalized

<1 are hospitalized in an academic medical center

Fig. Results of a reanalysis of the monthly prevalence of illness in the community and the roles of various sources of health care. (Green LA et al., N Engl J Med 2001, 344:2021-2024)

“If we want more Evidence-Based Practice, we need

more Practice-Based Evidence”

Larry W. GreenUS-PSTF, CDC, HHS

The OCHIN PBRN Mission

• Our mission is to:• Improve the health of underserved populations• Enhance their quality of care• Inform health policy through research

• We are unique among PBRNs• Housed at a community nonprofit organization• Made up exclusively of health centers that serve a safety

net population

OCHIN Research Infrastructure• OCHIN research team• Key partnerships with Kaiser Permanente

Center for Health Research and Oregon Health & Science University

• Building new partnerships as we speak

Our OCHIN Research Team

Jen DeVoeVance BauerChristine NelsonStuart CowburnJon PuroTrisha VakarcsSonja LikumahuwaJennifer LembachJill Arkind

Our Research PrioritiesStudies that examine effective interventions and

delivery system improvements • Understanding and addressing health conditions with known

health disparities that are common in safety net populations;• Improving health outcomes in safety net populations;• Evaluating interventions that have potential to improve safety

net practice;• Testing health IT interventions to improve population health;• Implementing evidence-based practices within the clinic

network.

Current OCHIN Research and Infrastructure Projects

Research• 12 active studies• 17 submitted grants in 2011-2012Infrastructure• 2 Infrastructure GrantsNational Networks/Collaborations• 4 National Networks

National Research Collaborations

• CHARN– Community Health Applied Research

Network – HRSA

• CER-HUB– Enhancing Clinical Effectiveness

Research with Natural Language Processing of EMR – AHRQ R01

• N2: A Network of the Safety Net• Meta-LARC

Types of Research Studies

• Data-only• Intervention

Linking EHR & Medicaid Data

• OCHIN’s EHR data contains >85% of FQHC visits in Oregon

• We linked– safety net clinic EHR data (>50 clinics in Oregon)– state Medicaid claims data

utilization data for all adult patients with diabetes in Oregon

… Regardless of insurance status!

Higher Receipt of Cholesterol Screening Associated With Continuous Medicaid

Coverage

Among partially insured, more coverage is no better than less coverage.

% of time insured, 2005-2007* Adjusted for gender, age, race / ethnicity, and Federal Poverty Level.

Types of Research Studies

• Data-only• Intervention

The A.L.L. Project

• “Translating” a very successful Kaiser national program (aspirin, lovastatin, lisinopril)– Significant reduction in cardiovascular events in

diabetics

• Using HIT Tools and other interventions to identify diabetic patients who may benefit from a specific drug regimen.

A.L.L. study: impact thus far!

Research Next Steps• Using the power of our data combined with other data

sources– National research datasets (NAMCS)– Claims datasets (Medicaid, All Payors/All Claims (APAC))– Other EHR systems and health organizations– GIS (Geographic Information System) – geocoding

• Disseminating and translating evidence-based, ‘tried and true’ projects into the safety net

• Studying ‘natural experiments’: ACOs/CCOs, Payment Reform, HIEs, etc.

• Working to engage clinicians, patients and other stakeholders

Practice Transformation

Quality ImprovementsWorkflow RedesignHealth Information Technology Support & DevelopmentTeam-based CareClinical Decision ToolsPatient Self-Care Personal Med Records

Research

Electronic Health Record Data, RegistriesPBRN InfrastructureMethodological & Data ExpertiseInforming PolicyInforming PracticeDisseminating Findings

Learner’s Bridge

How can you be involved?

• Sign-up sheet to be added to distribution list• Call into monthly PBRN meetings (4th Fridays,

7:30am – 8:30am Pacific)– NEXT MEETING: NOVEMBER 30

• Tell us about your research and QI projects and ideas!

Email: research@ochin.org

Learning From You – Small Groups• What has your experience been with research? • Based on your experience, what are best practices and

preferences for recruiting and compensating clinics, providers and patients for research studies?

• We are looking for ways to engage patients in our research. How have you involved the patient perspective in your own research or QI initiatives?

• What are your top research priorities?• How can researchers learn about (and study!) the

innovative things that your organization is doing?• What successful initiatives could be ‘translated’ from

your organization to others?

707 SW Washington Street Suite 1200 • Portland OR 97205 • Phone 503.943.2500 • Fax: 503.943.2501 Email: info@ochin.org • www.ochin.org

Thank you!

Questions?