Using the Electronic Health Record to Improve the Quality of Pediatric Primary Care

1. Using the Electronic Health Record to Improve the Quality of Pediatric Primary Care William G. Adams, MD Associate Professor of Pediatrics Director of Child Health Informatics Boston University School of Medicine/Boston Medical Center badams@bu.edu

2. Setting Boston Medical Center • Largest safety net hospital in Massachusetts • 30,000+ pediatric primary care visits annually • Extremely diverse ethnicities (23+ languages) • Began using Logician/Centricity in 2000 Boston HealthNet • Affiliated network of independent community health centers (CHCs) in Boston • 7 CHCs able to implement Logican/Centricity EHR in 2002 (the CHART Project)

3. Evolution of an Urban Child Health Information System • 1995 • Laboratory Data Import • Immunization Registry • 1996 • On-line Hearing and Vision Screening • 1998 • On-line Immunization Entry and Exchange • Implementation of the Automated Record for Child Health (ARCH) • 2001 • Logician EMR and HL7 data transfer • 2002 • Logician Extended to 8 Boston CHCs • 2003 • Pediatric Logician Users Group (PLUG) • 2004 • QI Warehousing and the Community Health Information for Improvement (CHII) Project • 2005 • Clinician- and Practice Performance Reporting • 2008 • Personal Health Partner at BMC • 2010 • Massachusetts Health Disparities Repository Registry Building Real-time Data Entry EMR-based Primary Care Population-based Primary Care

4. Real-time (Point-of-Care) Immunization Data Entry

5. Missing Doses Before and After Intervention

6. Forms printed 1999-2000 # more than 100,000 dates printed in first 12 months

7. The ARCH Comprehensive pediatric primary care electronic health record (EHR) Based on evidence-based structured encounter forms Users encouraged to provide entries as structured data

8. Before…

9. ARCH Risk Assessment Pediatrics, March 2003

10. Clinician+ Assessment* of ARCH Visits + 5 Attendings and 2 PNPs who completed > 50 ARCH patient visits * “Compared to documentation of primary-care in the paper record, The ARCH:" Pediatrics, March 2003

11. Strengths and Limitations Following EHR Implementation - 2003 • Strengths: • Access to data • Structured approach to preventive care • Limitations • Missing information • Multi-problem visits • Limited decision support • No structured approach chronic illness • Major barriers to using data for quality reporting (easy in, impossible out)

12. The Boston Pediatric Logician Users Group (PLUG) Voluntary group Clinicians and analysts from CHCs and BMC Began in 2003 after first year of full CHC EHR implementation Driven be pressing need to improve the quality of our pediatric primary care HIT with limited resources

13. System Re-design: Usability

14. PLUG Re-design: 18 Forms to 1 Form Before After

15. PLUG Re-design: Multi-problem Visits and Navigation Bar Before After

16. PLUG Re-design: Comprehensive RHCM and Asthma Care • RHCM: • Age-based template selection • Three domains: Hx, Risk, Development • Asthma: • Six Forms -> one • Driven by clinical care • Designed to support quality measurement

17. Symptom Assessment Acute Care Use

18. Community Health Information for Improvement (CHII) Project 6 CHCs and BMC Integrated EHR-based data warehouse with 50,000 children < 19 yrs Provider reflects on performance through personalized and practice-based data Performance reports automatically generated and emailed to clinicians monthly

19. How Canan EHR Support Better Care? • Comprehensive care • Longitudinal care • Decision making and support • Team work • Performance assessment • Case management

20. Comprehensive Care: Improving BMI, Dental, and Depression Screening

22. % of Visits for Children 3-18 with BMI Recorded during RHCM Visits

24. % of Visits for Children 3-12 with Dental Care Assessed during RHCM Visits

26. % of Visits for Children < 1 Year Old with Maternal Depression Assessment in Past 12 Months RHCM Visits Any Visit

27. Decision Making and Support: Immunizations and Point-of-care Recommendations

32. Team Work:Asthma Form shared between Specialty and Primary Care

34. % of Visits* for Children with Asthma with Severity Classification * For children with any asthma diagnosis on problem list

35. % of Visits for Children with Persistent Asthma* with a Controller Rx within the past 12 months * Diagnosis of persistent asthma on problem list

36. Symptom Assessment Acute Care Use

37. % of Visits for Children with Persistent Asthma* with Symptom Assessment within 12 Months * Diagnosis of persistent asthma on problem list or a controller Rx in past 12 months

39. % of Visits for Children with Persistent Asthma with an Asthma Action Plan within 12 Months * Diagnosis of persistent asthma on problem list or a controller Rx in past 12 months

40. Sample Measure for Practice Six measures sent in each clinician and practice report

41. CHII Performance (all Centers) Before and After Reporting • performance based on visits for any reason for children with asthma • Controller prescribing (at least 1 Rx in the previous 12 months for patients with a diagnosis of persistent asthma was 93-95% throughout study

42. When is a lot, enough? Fast Comprehensive data Information-less Paralysis

43. New AAP Efforts/Activities • AAP Child Health Informatics Center (CHIC) • Model Pediatric EHR Format (Weststat, AAP, AAFP, others) • ePROS