Kwame A' Kitson, MD

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EHR IMPACT ON QUALITY MEASURES AND POPULATION
HEALTH IMPROVEMENTS THE REASON FOR BOTHERING
Kwame A. Kitson, MD VP of Quality
Improvement Institute for Urban Family Health 16
East 16th St New York, NY 10003 kkitson_at_
institute2000.org 212-633-0800 www.
institute2000.org
EHR Pathway to Healthier Communities MAY 2005
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QUALITY IMPROVEMENT DEMANDS ON CHCS

• NATIONAL
• National Voluntary Consensus Standards for
  Ambulatory Care An Initial Physician-focused
  Performance Measurement Set. The National Quality
  Forum has initiated 50 proposed national
  voluntary consensus standards for measuring and
  reporting the quality of ambulatory care.
• NCQA Reviews Health Plan Performance based on
  HEDIS. HEDIS is the performance measurement tool
  of choice for more than 90 percent of the
  nations managed care organizations. There are
  over 70 different HEDIS measures ranging from
  review of cervical cancer screening to smoking
  cessation and customer satisfaction.
• JCAHO Ongoing continuous quality improvement
  expected.

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QUALITY IMPROVEMENT DEMANDS ON CHCS

• REGIONAL
• Local Departments of Health- HEDIS measures
  often used.
• LOCAL
• Use of Quality incentives by PPOs, other medical
  groups.
• Internally Driven CQI to satisfy Grant
  requirements.

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IUFH QI READINESS PRE-EHR

• Access to internal data greatly limited.
• Resource allocation limited organization- wide QI
  topic review to three topics per year.
• Areas covered included comprehensive HIV review,
  diabetes, adolescent screening for tobacco and
  substance abuse, postpartum care
• Interventions that worked best were those that
  facilitated better documentation by providers
  (e.g. Stamps)

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IUFH QI READINESS PRE-EHR

• Average time spent on chart review- 30 minutes to
  one hour per chart depending on the study
• Average length it took to complete Pre-EpicCare
  studies- three months.
• Chart reviewers were doctors and nurses at our
  clinics. Time spent on chart review made it more
  difficult for them to complete other
  administrative tasks.

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OUTCOMES

• IUFH transitioned all 13 clinics into EpicCare
  between October 2002 and January 2003
• Within the first six months provider productivity
  matched pre-EpicCare levels.
• In 2004, unprecedented productivity levels have
  been seen.

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Outcomes

• Ease of information retrieval
• Availability of reports relevant to CHCs
• Ease of development of custom reports
• Ease of running ad-hoc reports

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October 2003- Release of Superhero Best Practice
Alerts
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IUFH BEST PRACTICE ALERTS

• PRIMARILY BASED ON HEDIS CRITERIA
• PNEUMOVAX
• SEASONAL FLUVAX
• BREAST CANCER SCREENING
• CERVICAL CANCER SCREENING
• LEAD SCREENING
• HGBA1C TESTING AND CONTROL

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IUFH BEST PRACTICE ALERTS

• OPHTHALMOLOGY CONSULTS FOR DIABETICS
• PEAK FLOW MEASUREMENTS FOR ALL ASTHMATICS
• NEPHROLOGY CONSULTS FOR PATIENTS WITH GREATER
  THAN 1.8 SERUM CREATININE
• LDL SCREENING
• ANNUAL RPR SCREENING IN HIV

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DID IT WORK ?

• Initial concern about the introduction of best
  practice alerts (BPAs) replaced by enthusiasm
  for the improvement seen in multiple clinical
  areas.
• Key to Success- Making sure that the BPAs were
  accurate in capturing services rendered (e.g.
  There are dozens of CPT codes utililized for
  Cervical Cancer screening)

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EXPONENTIAL INCREASE IN REPORTING CAPABILITIES

• EPICCARE/CLARITY DATABASE WITH CRYSTAL REPORTING
  HAVE ALLOWED FOR AN EXPONENTIAL INCREASE IN
  REPORTING.
• OVER A DOZEN CLINICAL AREAS ARE BEING REVIEWED
  SIMULTANEOUSLY
• POTENTIAL FOR REVIEW IS LIMITLESS

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Well Child 3 to 6 Visit Rates
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Well Adolescent 12 to 21 Visit Rates
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LEAD TESTING IN TWO YEAR OLDS
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HEMOGLOBIN A1C TESTING RATES
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HEMOGLOBIN A1C CONTROL
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HEMOGLOBIN A1C ROLLING 12 MONTH AVERAGE SCORE
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PNEUMOVAX
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CERVICAL CANCER SCREENING PER VISIT
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MAMMOGRAMS PER VISITFemales Ages 40-70
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OPHTHALMOLOGY CONSULTS FOR DIABETICS
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Patients with last Sys BPgt180 or Diast BP gt 110
not seen in the past 3 months
In this period 8 people were removed from the
list and 9 added
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4Q02
2Q03
1Q04
4Q03
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Syndromic SurveillanceEarly warning of Viral GI
activity
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LESSONS LEARNED

• ORGANIZATIONAL READINESS
• SYSTEM SELECTION
• IMPLEMENTATION
• RETURN ON INVESTMENT

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ORGANIZATIONAL READINESS

• Essential
• Spirit of innovation
• Financial strength
• Stability
• Absence of concurrent threats
• Beneficial
• Enthusiasm of medical/nursing leadership
• Existing IT expertise

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System Selection

• Picking the Company
• Financial strength
• Size and longevity of company
• History of the product
• Local support capability
• Training methods
• Implementation planning
• Stock performance
• Portfolio of interests

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System Selection

• Picking the Product
• Product cycle
• Use of state-of-the-art technology
• Pick 5-10 evaluation items critical to your
  Center, e.g.
• Link procedures gt billing
• Interfaces labs/ immunization registry
• Drug gt drug interactions
• Best Practice alerts
• Compatibility of workflows

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Implementation Hints

• Implement the full system at once phased
  implementation increases work and prolongs the
  pain and anxiety
• Stagger implementation of sites by only a few
  weeks
• Have plenty of resources in house at go-live
• Set a 100 cut-over date

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Implementation Hints

• Let the old charts age out
• Abstract only
• Problem lists
• Medication lists and immunization hx
• Critical reports, consults, tests
• Start work on the interfaces on day 1 after
  contract signing they take the longest to
  develop

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RETURN ON INVESTMENT ???

• Return ?
• Improved Provider Productivity? Probably
• Improved Efficiency of Support Staff ? NO
• Reduction in Support Staff ? NO - Increase
• Improved Outcomes for Patients in
  Pay-for-performance Plans ? Yes Need to
  Develop this
• Improved staff retention? Unknown
• Improved patient satisfaction? Definitely
• Increased physician work in patient follow-up and
  outreach
• Need for new staff for software, hardware,
  network support
• Need to develop outreach staff for report
  follow-ups

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DENOMINATOR PATIENTS IDENTIFIED BY MID YEAR
REPORT AS NOT HAVING SERVICE PERFORMED NUMERATOR
PATIENTS OUTREACHED TO ON MID YEAR REPORT WITH
THE SERVICE PERFORMED BY 12/31/04
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RETURN ON INVESTMENT ANALYSIS

• Ongoing Costs
• Equipment Maintenance
• Servers Communication Desktop
• Communication Lines
• Software Maintenance / Enhancements
• Ongoing Training Costs
• Maintenance of Training Center
• Rent and Maintenance of Offices for IT Team
• Lost (or Gained) Productivity of Providers
• Continued Recruitment, Hiring and Training of IT
  team

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EPIC IMPLEMENTATION COSTS 13 CENTERS

• 13 Health Centers
• 65,000 Users 175,000 Visits
• 50 Primary Care Providers
• Total costs 3 million

Total Capital Cost 50,000 per provider