Primary Care Information Project

1. Trend of quality measures following implementation of electronic health record systems amongst practices in underserved urban areas Jason Wang, Ph.D.Sr. Director of Program Evaluation and AnalysisPrimary Care Information ProjectNYC Department of Health & Mental Hygiene APHA 140th Annual Meeting San Francisco, CA October 30, 2012 Primary Care Information Project

2. INTRODUCTION Objective: Assess the overall trend for some key quality measures for practices in underserved urban areas after implementation of EHR. Background: In transforming primary care, studies showing sustained improvements in the delivery of clinical preventive services are limited. Fewer demonstrate sustained improvements among independent practices that are not affiliated with hospital or integrated health systems. This study examines the continued improvement in clinical quality measures for a group of practices using electronic health records and receiving technical support from a local public health agency. Methods: Clinical quality measure performance data were analyzed from a cohort of primary care practices that implemented an electronic health record (EHR) at least three months before baseline (October 2009). Trends were observed for four key quality measures: antithrombotic therapy, blood pressure control, smoking cessation intervention, and A1c testing based on monthly summary data transmitted by the practices over a two-years period.

3. Advancing NYC’s Health Priorities Have a Regular Doctor or Other Health Care Provider Be Tobacco-Free Keep Your Heart Healthy Know Your HIV Status Get Help for Depression Live Free of Dependence on Alcohol and Drugs Get Checked for Cancer Get the ImmunizationsYou Need Make Your Home Safe and Healthy Have a Healthy Baby • Large burden, killing thousands of NYers and causing hundreds of thousands of preventable illnesses or disabilities each year • Proven amenable to intervention • Best addressed through coordinated action by City agencies, public-private partnerships, health care providers, businesses, individuals • Important and winnable battles that affect every New Yorker

4. Primary Care Information Project (PCIP) PCIP started as a mayoral initiative in 2005 Mission Improve the quality of care in medically underserved areas through health information technology (HIT) Success Over 6,200 providers receiving EHR and Meaningful Use assistance 915 small practices, 23 large practices 50 community health centers 54 hospitals & outpatient clinics

5. Table 1. Description of quality measures

6. Table 2. Baseline Practice Characteristics Mean Practice Values for Small Practices (SP) and Community Health Centers (CHC)

7. Graph 1. Overall Progress in PCIP – 2 year trend

8. Table 3. Improved Quality Measure Performance over Time Stratified by Various Practice Characteristics

9. Table 4. Results of Generalized Estimating Equation (GEE) Model

10. DISCUSSION Two year trends of 151 independent practices show significant gains on four quality measures. Our findings suggest that independent small practices and community health centers, with the assistance from a community EHR extension program such as PCIP, can achieve clinical quality gains similar to those observed in larger, well-resourced integrated delivery systems. Our findings are particularly relevant to independent practices serving resource-challenged urban areas. Of the practice characteristics we analyzed, none accounted for consistent differences in the increases observed with the exception of duration using an EHR. In this study we observed increases of several percentage points per year, suggesting that long-term improvement can also occur. This continued progress supports the idea that urban independent practices can drive long-term improvements in population health, a finding that is especially promising since inner-city independent practices like those served by PCIP tend to see a larger than average number of patients who are both uninsured and suffering from more severe health issues. Continued support is needed to help independent primary care practices get the most from health IT as an investment to improve health care and focus on patient-centered, outcomes driven care and coordination. .

11. Several practices that adopted an EHR in the timeframe eligible for inclusion in the analyses were not able to transmit data and their performance on the indicators in this study are unknown, though practices with missing data have similar characteristics as those represented in the study. Providers working with PCIP represent a group of EHR users who have received a variety of assistance from PCIP staff, including training and guidance on quality improvement strategies, technical support on EHR software (upgrades, patches, and configuration), and connection for health information exchange. Comparable data are not available to ascertain whether providers who do not have access to the same types of assistance would experience similar improvement trends. Improvement due to better documentation alone in the EHR was not tested in this study. For lab tests where an electronic lab interface was not available and the practice does not routinely enter results into the patient’s record, practice rates on these tests will be under reported. Factors such as incentives, availability of CDSS alert, number of QI visits, PCMH recogization, etc. will be put into the analysis to detect significant driving forces for the quality measures improvement. LIMITATION and NEXT STEPS 11

12. OTHER PCIP STUDIES (1). Health Information Systems in Small Practices: Improving the Delivery of Clinical Preventive Services. AJPM. November 2011. 

13. OTHER PCIP STUDIES (2). Validity of EHR Derived Quality Measurement for Monitoring Population Health & Clinical Quality.JAMIA. Feb 2012.

14. OTHER PCIP STUDIES (3). Decline and Rebound: Population Trends in Performance on Clinical Quality Measures in Small Practices Adopting Electronic Health Records. Academy Health Annual Meeting, Orlando, FL. June 2012.

15. OTHER PCIP STUDIES (4). Two year quality trends for independent practices adopting an EHR and achieving PCMH recognition. AHRQ Annual Meeting, Washington DC, September 2012.

16. Acknowledgments Authors: Jason J. Wang PhD, Kimberly M. Sebek MPH, Colleen M. McCullough BA, Sam C. Amirfar MD, Amanda S. Parsons MD, MBA, Jesse Singer DO, MPH, Sarah C. Shih MPH Contact: Jason Wang, Ph.D., Sr. Director of Program Evaluation and Analysis Primary Care Information Project, NYC Department of Health and Mental Hygiene Long Island City (Queens), NY 11101. Tel: (347) 396-4859, Email: jwang5@health.nyc.gov Acknowledgments: The authors would like to acknowledge Dr. Thomas Farley, Commissioner of the New York City Department of Health for the valuable input on this study. The authors also wish to thank the PCIP staff for their tremendous dedication and participating practices’ commitment to improving health in New York City. Funding: A portion of this study was supported by the Agency for Healthcare Research and Quality (grant #s R18HS17059 and 17294). The funder played no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the paper for publication