Bridging the gap between clinical practice and public health: Using EHR data to assess trends in the seasonality of blood-pressure control.

Electronic health records (EHRs) provide timely access to millions of patient data records while limiting errors associated with manual data extraction. To demonstrate these advantages of EHRs to public health practice, we examine the ability of a EHR calculated blood-pressure (BP) measure to replicate seasonal variation as reported by prior studies that used manual data extraction. Our sample included 609 primary-care practices in New York City. BP control among hypertensives was defined as systolic blood pressure of 140 or less and diastolic blood pressure of 90 or less (BP < 140/90 mm Hg). An innovative query-distribution system was used to extract monthly BP control values from the EHRs of adult patients diagnosed with hypertension over a 25-month period. Generalized estimating equations were used to compare the association between seasonal temperature variations and BP control rates at the practice level, while adjusting for known demographic factors (age, gender), comorbid diseases (diabetes) associated with blood pressure, and months since EHR implementation. BP control rates increased gradually from the spring months to peak summer months before declining in the fall months. In addition to seasonal variation, the adjusted model showed that a 1% increase in patients with a diabetic comorbidity is associated with an increase of 3% (OR 1.03; CI 1.028-1.032) on the BP measure. Our findings identified cyclic trends in BP control and highlighted greater association with increased proportion of diabetic patients, therefore confirming the ability of the EHR as a tool for measuring population health outcomes.

Applied Use of Composite Quality Measures for EHR-enabled Practices.

INTRODUCTION: The Primary Care Information Project (PCIP) of the New York City Department of Health and Mental Hygiene has been assisting providers to implement health information technology such as electronic health records (EHRs) since its founding in 2005. Currently, all practices affiliated with PCIP are offered technical support services in order to improve the use of the EHR. We studied the performance of clinical practices on EHR-derived Composite Quality Measures (CQMs) over time. Because specific EHR functionalities are important to calculating the quality measures, we hypothesize that performance on each of the CQMs will differ according to the EHR functionalities, and that this can inform the process of developing targeted technical assistance for the practices. METHODS: We created four CQMs: (1) Screening, (2) Assessment, (3) Control-BP, and (4) Control-Other. Using data from 93 practices, we identified three tertiles of CQM performance (premier, average, and low tiers) for each measure. A scatterplot of CQMs in 2010 versus 2011 was used to examine the individual movement of practices by tier. A dependent t-test compared the change in mean CQMs, and a chi-square test examined the association between the score and performance tier changes. RESULTS: Over a one-year period, low tier practices demonstrated the highest gains, average tier practices had modest gains, and premier tier practices had gains in some measures, but losses in others. On the Screening CQM 70 percent of practices remained within the same tier, with 60 percent on Assessment, 52 percent on Control-BP, and 38 percent on Control-Other; the Control-Other group showed the greatest improvement. DISCUSSION: By considering EHR functionalities associated with each of the four CQMs, we suggest that technical assistance can be better targeted to low-tier performing practices. In addition, there is still the potential for improvement over time at practices more familiar with key functionalities.

Developing Composite Quality Measures for EHR-Enabled Primary Care Practices in New York City.

We describe the process of developing composite quality measures (CQMs). During the initial consultative process, we grouped quality measures based on the associated clinical workflow and difficulty, and then confirmed the groupings with factor analysis. The CQMs are estimated as the mean of the measures for each group. We used analysis of variance followed by a post hoc analysis to assess: (1) performance among the different CQMs each year; and (2) the performance trend for each of the composite measures from 2009 to 2011. The four CQMs were Control-BP, Control-Other, Assessment, and Screening. Performance was highest at baseline for Control-BP (58%, SD 15.07), followed by Control-Other (48.04%, SD 22.75), Screening (46.49%, SD 20.21), and Assessment (42.15%, SD 19.08). Performance on the CQMs increased significantly with time, whereas the gap between the CQMs decreased significantly over time. The CQMs reflect the clinical care domains, and practice performance is influenced by electronic health record functionality, clinician workflow, and clinical difficulty.

Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems.

INTRODUCTION: Studies showing sustained improvements in the delivery of clinical preventive services are limited. Fewer studies demonstrate sustained improvements among independent practices that are not affiliated with hospitals or integrated health systems. This study examines the continued improvement in clinical quality measures for a group of independent primary care practices using electronic health records (EHRs) and receiving technical support from a local public health agency. METHODS: We analyzed clinical quality measure performance data from a cohort of primary care practices that implemented an EHR at least 3 months before October 2009, the study baseline. We assessed trends for 4 key quality measures: antithrombotic therapy, blood pressure control, smoking cessation intervention, and hemoglobin A1c (HbA1c) testing based on monthly summary data transmitted by the practices. RESULTS: Of the 151 practices, 140 were small practices and 11 were community health centers; average time using an EHR was 13.7 months at baseline. From October 2009 through October 2011, average rates increased for antithrombotic therapy (from 58.4% to 74.8%), blood pressure control (from 55.3% to 64.1%), HbA1c testing (from 46.4% to 57.7%), and smoking cessation intervention (from 29.3% to 46.2%). All improvements were significant. CONCLUSION: During 2 years, practices showed significant improvement in the delivery of several key clinical preventive services after implementing EHRs and receiving support services from a public health agency.

The Hub Population Health System: distributed ad hoc queries and alerts.

The Hub Population Health System enables the creation and distribution of queries for aggregate count information, clinical decision support alerts at the point-of-care for patients who meet specified conditions, and secure messages sent directly to provider electronic health record (EHR) inboxes. Using a metronidazole medication recall, the New York City Department of Health was able to determine the number of affected patients and message providers, and distribute an alert to participating practices. As of September 2011, the system is live in 400 practices and within a year will have over 532 practices with 2500 providers, representing over 2.5 million New Yorkers. The Hub can help public health experts to evaluate population health and quality improvement activities throughout the ambulatory care network. Multiple EHR vendors are building these features in partnership with the department's regional extension center in anticipation of new meaningful use requirements.

Developing public health clinical decision support systems (CDSS) for the outpatient community in New York City: our experience.

BACKGROUND: Developing a clinically relevant set of quality measures that can be effectively used by an electronic health record (EHR) is difficult. Whether it is achieving internal consensus on relevant priority quality measures, communicating to EHR vendors' whose programmers generally lack clinical contextual knowledge, or encouraging implementation of EHR that meaningfully impacts health outcomes, the path is challenging. However, greater transparency of population health, better accountability, and ultimately improved health outcomes is the goal and EHRs afford us a realistic chance of reaching it in a scalable way. METHOD: In this article, we summarize our experience as a public health government agency with developing measures for a public health oriented EHR in New York City in partnership with a commercial EHR vendor. RESULTS: From our experience, there are six key lessons that we share in this article that we believe will dramatically increase the chance of success. First, define the scope and build consensus. Second, get support from executive leadership. Third, find an enthusiastic and competent software partner. Fourth, implement a transparent operational strategy. Fifth, create and test the EHR system with real life scenarios. Last, seek help when you need it. CONCLUSIONS: Despite the challenges, we encourage public health agencies looking to build a similarly focused public health EHR to create one both for improved individual patient as well as the larger population health.

Study of electronic prescribing rates and barriers identified among providers using electronic health records in New York City.

BACKGROUND: Increased electronic prescribing (eRx) rates have the potential to prevent errors, increase patient safety, and curtail fraud. US Federal meaningful use guidelines require at least a 40% electronic prescribing rate. OBJECTIVE: We evaluated eRx rates among primary care providers in New York City in order to determine trends as well as identify any obstacles to increased eRx rates required by meaningful use guidelines. METHODS: The data we analysed included automatic electronic data transmissions from providers enrolled in the Primary Care Information Project (PCIP) from 1 January 2009 to 1 July 2010 and follow-up telephone calls to a subset of these providers to identify potential barriers to increased eRx usage. RESULTS: Over the course of the study, these providers increased the eRx rate from 12.9 to 27.5%, with an average rate of 24.1%. Conversations with providers identified their perceived barriers to increased eRx use as primarily patient preference for paper prescriptions and a belief that many pharmacies do not accept eRx. CONCLUSIONS: The data gathered from our providers indicate that there is an increasing trend in the eRx rate to 27.5% by July 2010, but still short of the 40% meaningful use level. However, obstacles to increased rates remain primarily providers' belief that many patients prefer paper prescriptions and many pharmacies are not yet prepared to accept electronic prescriptions.

Modeling the impact of a partially effective HIV vaccine on HIV infection and death among women and infants in South Africa.

OBJECTIVE: To assess the potential impact over 10 years of a partially effective HIV vaccine in a cohort of 15-year-old adolescent girls in South Africa in terms of HIV infections and deaths prevented in mothers and infants. METHODS: A computer simulation was constructed using a population of all 15-year-old adolescent girls in South Africa followed for 10 years. A partially effective vaccine is introduced into this population with the ability to reduce the HIV incidence rates of the adolescents and vertical transmission to their infants through birth and breast-feeding. At the end of this 10 year period, the number of HIV infections and death prevented in adolescents and infants is analyzed. RESULTS: Using a 5% HIV incidence rate, a 50% effective vaccine decreases the number of HIV cases among adolescents by 57,653 (28.7%) and the number of cases among infants by 13,765 (28.9%) over 10 years. In addition, assuming a vaccine cost of $20 per dose, the vaccination program can save approximately $120 million for the South African government over 10 years. CONCLUSION: A partially effective HIV vaccine has an important role in HIV prevention in adolescents and infants in South Africa irrespective of other public policy implementations.