Health Information Technology: The Next Frontier

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Health Information Technology The Next Frontier
Amanda Parsons M.D., M.B.A. Assistant
Commissioner Primary Care Information Project NYC
Department of Health Mental Hygiene
Empire State Medical Association
November 5th , 2010
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Disclosure None
3
AGENDA

• EMR Adoption Landscape Federal Strategy
• PCIP NYC REACH
• How to Join

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HISTORICAL UPTAKE OF EMRs HAS BEEN VERY LOW
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BUT THAT IS ALL RAPIDLY CHANGING

• Existing forces
• New providers going straight to EMR
• Stark law relaxation
• More EMR choices
• Almost all other industries have digitized
• Internet Age

• Within the next 5-10 years
• The paper chart will no longer exist,
  particularly in hospitals outpatient primary
  care sites

• New forces
• 48 billion in Medicaid/Medicare Meaningful Use
  incentives
• 598 million for Regional Extension Centers
• Other incentives PCMH, eprescribing
• Health care reform

• At least 100,000 providers, nationwide, are going
  through this transformation together
• Weve gotten 2,018 NYC providers live in 2 years

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NEW FEDERAL FUNDING SOURCES FOR HIT

• 1) 40 billion through CMS
• Meaningful Use funding goes to providers and
  practices to partially reimburse and reward
  investment in, and use of, EMRs
• 2) 2.1 billion through HHS (ONCHIT)
• 600 million Extension Center funding goes to
  extension centers to provide technical assistance
  to providers
• Other funding includes
• Health information exchange, Workforce
  development, Beacon communities

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THE FEDERAL HIT STRATEGY- HOW ALL IT ALL FITS
TOGETHER
Regional Extension Centers
Wide scale EMR Adoption
Beacon Communities
Workforce development

• Improve
• individual population health
• health outcomes
• transparency efficiency
• Ability to study improve care delivery

Meaningful Use framework
Meaningful Use of EMR
CMS Meaningful Use incentives
State Health Information Exchange
Standards Certification framework
Exchange of health information
Privacy Security framework
NHIN Direct
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OVERVIEW OF MEANINGFUL USE

• The American Recovery and Reinvestment Act (ARRA)
  authorizes the Centers for Medicare Medicaid
  Services (CMS) to offer a financial incentive to
  physician and hospital providers who demonstrate
  the meaningful use of an electronic health
  record (EHR).
• According to the CMS, a provider uses an EHR
  meaningfully when he or she
• 1) Improves quality, safety, efficiency, and
  reduce health disparities
• 2) Engages patients and families
• 3) Improves care coordination
• 4) Improves population and public health
• 5) Ensures adequate privacy and security
  protections for personal health information

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WORKING BACKWARD FROM THE GOAL
3 Stages of Meaningful Use

• Improved quality of care

Stage 3
Stage 2
Stage 1
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MEANINGFUL USE GOALS OVER THE NEXT 5 YEARS

• 1) Improve quality, safety, efficiency, and
  reduce health disparities
• Provide access to comprehensive patient health
  data for patients health care team
• Use evidence-based order sets and CPOE
• Apply clinical decision support at the point of
  care
• Generate lists of patients who need care and use
  them to reach out to patients
• Report to patient registries for quality
  improvement, public reporting, etc.
• 2) Engage patients and families
• Provide patients and families with timely access
  to data, knowledge, and tools to make informed
  decisions and to manage their health
• 3) Improve care coordination
• Exchange meaningful clinical information among
  professional health care team
• 4) Improve population and public health
• Submit immunization, syndromic surveillance and
  reportable disease data to public health agencies
• 5) Ensure adequate privacy and security
  protection for personal health information
• Ensure privacy and security protections for
  confidential information through operating
  policies, procedures, and technologies and
  compliance with applicable law
• Provide transparency of data sharing to patient

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WHO WILL BE ELIGIBLE FOR MEANINGFUL USE?

• Medicaid
• Eligible professionals include doctors of
  Medicine, Osteopathy, dental surgery, podiatric
  medicine, optometry, nurse practitioners and some
  physician assistants
• Must meet minimum Medicaid patient volume
  percentages
• 30 minimum for physicians treating adults
• 20 minimum for pediatricians
• Payments are fixed and not proportional to
  Medicaid billings. Up to 63,750 over 6 years
• If pediatricians qualify at 20, only eligible
  for 67 (2/3) of payments
• Cannot receive duplicative Medicaid and Medicare
  Ambulatory EHR incentives
• Medicare
• Eligible professionals include doctors of
  Medicine, Osteopathy, dental surgery, podiatric
  medicine and optometry,  
• Hospital-based physicians who substantially
  furnish their services in a hospital ambulatory
  setting are now eligible
• Payments increased by 10 for physicians
  practicing in a Health Professional Shortage Area

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WHAT IS AN EXTENSION CENTER?

• Federally designated non-profit organization
• One per region- 62 Nationwide
• NYC- NYC REACH
• Rest of NY State - NYeC
• Provides assistance with
• EHR vendor selection pricing
• Go-live project management support
• Onsite training Quality Improvement
• Achievement of Meaningful Use
• Ensure providers have a place to get qualified
  and unbiased support

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AGENDA

• EMR Adoption Landscape Federal Strategy
• PCIP NYC REACH
• How to Join

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PCIP- WERE IN THIS FOR THE RIGHT REASONS
ELECTRONIC HEALTH RECORDS oriented to prevention
Vision Healthcare that maximizes health
POPULATION MANAGEMENT practice workflows to
support prevention
PAYMENT that rewards disease prevention chronic
disease management
Mission To improve population health in
disadvantaged communities through the use of HIT.
In order to accomplish this transformation, EHR
adoption is not enough. We must re-orient EHRs,
practice workflows, and healthcare reimbursement
towards prevention with an emphasis on clinical
interventions with the greatest potential to save
lives
Frieden TR, Mostashari F. JAMA. 2008 Feb
27299(8)950-2.
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EVOLUTION OF PCIP
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WE ARE THE LARGEST EHR COMMUNITY PROJECT IN THE
NATION
Providers enrolled in PCIP
Practices Sites Providers
Hospitals 4 45 769
CHCs 37 99 806
Small practices 488 535 1051
Correctional Health Facility 1 1 70
Total 530 679 2696
2,225 are live
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SERVICES WE PROVIDE TO PRACTICES TO GET THEM LIVE
AND TO MEANINGFUL USE
Go live
Contemplation
Implementation
Post go live
Meaningful use

• Provider outreach education
• Conferences
• Webinars
• Vendor selection
• Readiness assessments
• IT consultation
• Partners for financing workforce development

• Contract accountability
• Project management
• Workflow redesign
• Social networking
• Communication outreach
• CME credits for training

• Revenue cycle optimization
• EMR consulting
• QI consulting
• PCMH preparation
• Privacy security consulting
• Work flow redesign Patient portal training
• Interfaces (e.g.,labs, registries)
• Pilots

• Quality measures
• Interoperability
• Patient engagement
• Biosurveillance
• Pay-for-Quality programs
• MU application support

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NYC REACH A NEW PROJECT OF PCIP
Primary Care Information Project

• Non profit program, founded by PCIP in 2010,
  funded through a federal grant
• Will help 2,400 additional providers go live on
  approved EHRs, including eCW
• Will help 4,543 providers get to Meaningful Use
  (2012)
• REC members have priority for other PCIP programs

• PCIP seeks to improve population health through
  health IT and data exchange.
• Part of NYC government
• Responsible for the initial eCW program
• Facilitates ongoing programs from implementation
  through improving health
• Pay for Performance
• Patient Outreach
• Public Health Surveillance

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NYC REACH - EHR ADOPTION SERVICES

• Vendor Selection
• What subsidies do you qualify for? Which EHR
  system is best for your practice needs?
• EHR discounts
• Negotiated group rates on NYC REACH preferred
  EHRs
• Cost/Benefit review for your practice
• Understand the estimated costs before you sign
  anything
• IT Support Recommendations
• List of proven IT support consultants to set up
  your system and keep your data secure.
• Pre- and Post-Implementation check ins
• NYC REACH Implementation Specialist helps you
  prepare for Meaningful Use before, during, and
  after system installation. Specialist is always
  available to answer your questions
• Integration with labs and city immunization
  registry
• Required for Meaningful Use

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DATA IS USED TO GENERATE QUALITY REPORTS FOR
PROVIDERS
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EMRS ENABLING BETTER P4P - BACKGROUND OF HEALTH
EHEARTS
Reward and recognize providers for delivering
excellent heart health (97 practices 473
providers)

• 6M grant from the Robin Hood Foundation
• One of the largest grants in Robin Hood
  Foundation history
• EHR serves as basis for rewards and recognition
• Prevention as a top priority
• Focus on an areas with maximum potential for
  saving lives in New York City
• Reduce disparities
• Incentive amounts are meaningful
• Pay on ALL patients
• Higher rewards for harder to treat patients

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GOOD NEWS WERE SEEING IMPROVEMENT IN DOCUMENTED
CLINICAL PREVENTIVE SERVICES

• Preliminary Findings
• Improvement across nearly all measures after use
  of EHR
• Current rates of services using automated EHR
  queries are likely lower than true delivery of
  services due to variation in documentation habits
• Study Methods (funded by AHRQ R18HS17059)
• Manual reviews of patient charts in two time
  periods
• First Time period after go-live and before
  implementation of CDSS
• Second Time period within 6 months after
  implementation of CDSS
• Random sample of 120 patients, ages of 18 - 75
  with at least one visit in past 2 years per
  practice
• Data shown includes 51 practices with over 6,000
  patients charts
• Future strategies
• Identify measures that can be reliably reported
  with EHR
• Work with providers to change documentation
• Work with EHR vendors to improve user interface
  to facilitate standard documentation

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RATES OF DOCUMENTED PREVENTIVE SERVICES ARE
INCREASING
Based on Manual Chart Reviews of 51 small
practices, sample of over 6,000 patients
plt0.05
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THE BAD NEWS WE STILL HAVE A LOT OF WORK TO DO
New York State ranks 36th on eprescribing
nationwide
Source Internal analysis, HQIN data
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MAJORITY OF INTERVENTION NOT CAPTURED FOR EMR
QUALITY MEASURES
This diagram displays the distribution of
documentation smoking status and cessation
intervention for patients seen in 41 practices
six month post implementation of a clinical
decision support system. Observations were
obtained through manual review of medical charts
for over 4,700 patients across 41 practices
(randomly selected 120 patients per practice)
Denominator Loss
Numerator Loss
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AGENDA

• EMR Adoption Landscape Federal Strategy
• PCIP NYC REACH
• How to Join

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HOW TO JOIN DETERMINE ELIGIBILITY

• Priority Settings
• Individual or small group practices (lt10
  providers)
• Public and Critical Access Hospitals
• Community Health Centers Rural Health Clinics
• Other settings that predominantly serve
  uninsured, underinsured and medically underserved
  populations

• Priority Providers
• Physicians, or other health care providers (PA
  NPs with prescriptive privileges)
• Includes ob/gyn, family medicine, general
  medicine and pediatrics
• OR Board certified Internal medicine AND
  practicing primary care for majority of patients
  at the location where you plan to apply for
  Meaningful Use

Eligible for subsidized services 600 per
provider capped at 6,000 per practice 1,200 EHR
Adoption Service fee waived
Providers not in these categories can get
services for full price 1,200 for EHR Adoption
Services 3,800 for Meaningful Use Curriculum
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HOW TO JOIN REVIEW OTHER SUBSIDIES
Certain groups may be eligible for additional
subsidies on some EHR software. An NYC REACH
Outreach Specialist will help identify which
offers apply to your practice. For example
High Medicaid Practice Specialists treating diabetic patients Interboro RHIO Continuum Hospital
NYC subsidized EHR free software, pay only 5,200 for technical assistance and 2 years of NYC REACH assistance Limited number of licenses (200 left) NYC subsidy/NY state grant Cost reduced to 6,000 for software and 2 years of NYC REACH assistance Available for MDs, DOs, NPs, and PAs licensed in cardiology, nephrology, endocrinology, ophthalmology, psychiatry, or podiatry. Limited number of licenses (lt10) Cost reduced to 1,380 for software and 2 years of NYC REACH assistance Available for practices in certain Queens/Northern Brooklyn zip codes Cost reduced to 780 for primary care/900 for specialists for software and 2 years of NYC REACH assistance Available for providers affiliated with Continuum Hospitals Limited number of licenses
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DONT LEAVE YOUR FRIENDS BEHIND
Speak with an Outreach Specialist today or fill
out an interest form at www.nycreach.org Or Atten
d our next Open House
December 15th, 2010 161 William St, 6th Floor,
Manhattan 530 730 PM To Register
http//nycreachopenhouse.eventbrite.com/
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Thank you, from the PCIP NYC REACH teams
www.nycreach.org
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WEVE MADE OVER 1,600 ONSITE VISITS TO PRACTICES
TO ASSIST WITH WORKFLOW REDESIGN
1,018
332
269

2009
2010
2008
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PUBLIC PRIVATE PARTNERSHIP MODEL
NYC Dept. of Health Mental Hygiene
Primary Care Information Project
Fund for Public Health in NY
ONC Funds
NYC funds
Robin Hood
gt45 million staff support
NY State funds
Engelberg
gt30 million
AHRQ, CDC, DHS
IPRO
gt 4 million
Private donors
Provider technical assistance contributions

• Managing 80 million in funding and 30-40
  projects

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Why Now? Time is limited
2010
2011
2012
2013
2014
2015
2016
2017
NYC REACH subsidized services
44,000
39,000
Medicare
24,000
63,750
Medicaid
Subsidy for Extension Center services initially
only funded for 2 years
Maximum Medicare payments go down over time, with
penalties starting in 2015
Providers must adopt by 2016 for full Medicaid
payment
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Why Now? Funding is limited

• NYC REACH has funding for 4,543 providers in New
  York City
• There are an estimated 30,000 providers
  practicing in the city
• 1,000 providers have already signed up since
  March
• The 1,200 EHR Adoption Fee is waived for a
  limited time
• Other subsidies (from DOHMH, hospitals, state
  funding) are limited

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Payment Results

• Year One Payments
• Practices with monetary incentives earned nearly
  1.6 million
• Total of 41 small practices and 13 large
  organizations received monetary incentives

Distribution of Payout Number of Providers Per Practice Number of Providers Per Practice Number of Providers Per Practice
1 to 2 3 to 10 gt10 Overall
Total Amount 374,700 317,640 880,260 1,572,600
Number of Practices 32 9 12 53
Average per practice 11,709 35,293 73,355 29,672
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OUR QUALITY MEASURES THE ABCS
Aspirin Therapy Ages 18 years or older with Ischemic Vascular Disease or ages 40 years or older with Diabetes on aspirin or another anti-thrombotic therapy
Blood Pressure Control Patients 18-75 years of age with Hypertension, without Ischemic Vascular Disease or Diabetes who have a BP lt 140/90
Blood Pressure Control Patients 18-75 years of age with a diagnosis of Diabetes AND Hypertension with the most recent BP below 130 systolic and 80 diastolic
Blood Pressure Control Patients 18-75 years of age with a diagnosis of Ischemic Vascular Disease AND Hypertension without Diabetes with a BP below 140 systolic and 90 diastolic
Cholesterol Control Male patients gt 35 years of age and female patients gt45 years of age without Ischemic Vascular Disease or Diabetes who have a total cholesterol lt 240 or LDL lt 160 measured in the past 5 years
Cholesterol Control Patients 18-75 years of age with a diagnosis of Ischemic Vascular Disease or Diabetes and Lipoid disorder who had a LDL lt 100 in the past 12 months
Smoking Cessation Patients ages 18 years or older identified as current smokers who received cessation interventions or counseling
A
B
C
S
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HEALTH eHEARTS YEAR 1 SUMMARY

• Year One Payments
• Practices with monetary incentives earned nearly
  1.6 million
• Total of 41 small practices and 13 large
  organizations received monetary incentives
• Preliminary Observations
• Regardless of incentives, practices increased
  their performance on ABCS
• Performance is lowest for Smoking Cessation
  Intervention
• Highest improvement seen in Aspirin Therapy and
  BP Control
• Issues with laboratory interface has a
  substantial impact on performance for Cholesterol
  Control

Distribution of Payout Number of Providers Per Practice Number of Providers Per Practice Number of Providers Per Practice
1 to 2 3 to 10 gt10 Overall
Total Amount 374,700 317,640 880,260 1,572,600
Number of Practices 32 9 12 53
Average per practice 11,709 35,293 73,355 29,672
Total of providers 43 59 674 776
Average earned per provider 8,714 5,384 1,306 2,027
Estimated Number of Patients 49,431 39,197 252,896 341,524
Number of Patients with Hypertension 8,883 7,056 37,592 53,531
of patients with Hypertension 18.0 18.0 14.9 15.7
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MAJORITY OF HYPERTENSION DIAGNOSIS AND VITALS
CAPTURED FOR AUTOMATED QUALITY MEASURE REPORTING
This diagram displays the distribution of
documentation for hypertension diagnosis and
blood pressure recording for patients seen in 41
practices six month post implementation of a
clinical decision support system. Observations
were obtained through manual review of medical
charts for over 4,700 patients across 41
practices (randomly selected 120 patients per
practice)
Denominator Loss
Numerator Loss
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IN ADDITION TO NYC REACH, PCIP RUNS MANY OTHER
PROGRAMS
You will have access to programs like these by
working with NYC REACH
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NYC REACH - MEANINGFUL USE CURRICULUM
Step 1 Learn Step 2 Prepare Step 3 Submit
Seminar Series Level 1 Meaningful Use Overview Install or upgrade your EHR Choose your program Medicare or Medicaid? Choose which measures are right for you Set up your labs, city immunization registry, and ePrescribing Seminar Series Level 2 Measure by Measure Site visits with NYC REACH staff Use NYC REACH Self-Assessment to identify problem areas Understand how to track your progress Seminar Series Level 3 CMS Application How to apply for your incentives and avoid mistakes that can cost you money Site visits to address potential problems
Upcoming December 16th Meaningful Use Seminars for members only!
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HEART DISEASE IS STILL THE LEADING CAUSES OF
DEATH IN NYC
Source Summary of Vital Statistics, NYC, 2008
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POTENTIAL DEATHS PREVENTED BY GREATER USE OF
CLINICAL PREVENTIVE SERVICES
Number of deaths prevented
Percent eligible utilizing service
Farley TA, Dalal MA, Frieden TR. Unpublished data
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WE RECEIVE AGGREGATE PRACTICE DATA INTO
HEALTHCARE QUALITY INFORMATION NETWORK (HQIN)
HQIN Data Warehouse

• Types of Information
• Take Care New York Indicators (also referred to
  as health care quality measures)
• Syndromic Surveillance (reports of flu, GI
  outbreaks)
• Use of EHR in care delivery (electronic
  prescribing, laboratory orders, reporting to
  community immunization registry)

• What is Reported?
• Counts of Patients
• -with specific diagnoses
• -receiving recommended clinical preventive
  services
• -Stratified by provider, practice, and insurance
  type

Insurance type currently distinguishes Managed
Care, Medicare FFS, Medicaid FFS, Uninsured, and
Other
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QUALITY PAYMENT TABLE- PAYING MORE FOR DISPARITIES
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PAID OUT 1.6 M, BUT INCONCLUSIVE WHETHER
INCENTIVES HAVE HAD AN IMPACT
Distribution of Payout Number of Providers Per Practice Number of Providers Per Practice Number of Providers Per Practice
1 to 2 3 to 10 gt10 Overall
Total Amount 374,700 317,640 880,260 1,572,600
Average per practice 11,709 35,293 73,355 29,672
Average earned per provider 8,714 5,384 1,306 2,027
2009
2008
No Incentives
Incentives
No Incentives
Incentives
Results
Rate (N)
Rate (N)
Rate (N)
Rate (N)
58.9 (39)
62.6 (41)
48.9 (33)
48.8 (41)
Aspirin Therapy
46.6 (39)
55.4 (41)
39.9 (34)
42.6 (41)
Blood Pressure Control
52.2 (38)
84.1 (38)
67.8 (24)
89.8 (25)
Cholesterol Control
28.4 (39)
35.1 (39)
18.6 (28)
19.6 (37)
Smoking Cessation Intervention
so extending study by one year to determine if
a difference can be seen
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HIGH LEVEL OVERVIEW

• Payors P4P or payment filter items

• Practices

• PCIP data warehouse

• Plans recognize providers

• yes

• HQIN

• For providers who want to participate

• Qualified providers are asked if they want to
  release data to plans

• Monthly transmissions (quality data utilization
  data)

• no

• Data is not released

• Allows us to partner with interested payors and
  practices to help administers pay-for-performance
  plans, reducing the administrative burden

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THE BAD NEWS WE STILL HAVE A LOT OF WORK TO DO
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New York State ranks 36th on eprescribing
nationwide
Surescripts published rankings Source Interna
l analysis, HQIN data