Challenges and strategies for hypertension management: qualitative analysis of small primary care practices with varying blood pressure control.

BACKGROUND: Electronic health record (EHR) data on blood pressure (BP) control among patients with hypertension show that practices' rates vary greatly. This suggests providers use different approaches in managing hypertension, and so we aimed to explore challenges small primary care practice providers face and strategies they use to manage patients' BP. We explored differences between providers with high and low BP control rates to help inform future quality improvement work. METHODS: In 2015, we recruited practices in New York City with five or fewer providers. We employed a stratified purposeful sampling method, using EHR data to categorize small practices into groups based on the proportion of patients with hypertension whose last BP was <140/90: high control (>= 80%), average control (60-80%) and low control (<60%). We conducted semi-structured qualitative interviews with clinicians from 23 practices-7 high control, 10 average control and 6 low control-regarding hypertension management. We used a combined inductive/deductive approach to identify key themes, and these themes guided a comparison of high and low BP control providers. RESULTS: Small practice providers reported treatment non-adherence as one of the primary challenges in managing patients' hypertension, and described using patient education, relationship building and self-management tools to address this issue. Providers differed qualitatively in the way they described using these strategies; high BP control providers described more actively engaging and listening to patients than low control providers did. CONCLUSIONS: How providers communicate with patients may impact outcomes-future quality improvement initiatives should consider trainings to improve patient-provider communication.

Testing the use of practice facilitation in a cluster randomized stepped-wedge design trial to improve adherence to cardiovascular disease prevention guidelines: HealthyHearts NYC.

BACKGROUND: HealthyHearts NYC (HHNYC) will evaluate the effectiveness of practice facilitation as a quality improvement strategy for implementing the Million Hearts' ABCS treatment guidelines for reducing cardiovascular disease (CVD) among high-risk patients who receive care in primary care practices in New York City. ABCS refers to (A) aspirin in high-risk individuals; (B) blood pressure control; (C) cholesterol management; and (S) smoking cessation. The long-term goal is to create a robust infrastructure for implementing and disseminating evidence-based practice guidelines (EBPG) in primary care practices. METHODS/DESIGN: We are using a stepped-wedge cluster randomized controlled trial design to evaluate the implementation process and the impact of practice facilitation (PF) versus usual care on ABCS outcomes in 250 small primary care practices. Randomization is at the practice site level, all of which begin as part of the control condition. The intervention consists of one year of PF that includes a combination of one-on-one onsite visits and shared learning across practice sites. PFs will focus on helping sites implement evidence-based components of patient-centered medical home (PCMH) and the chronic care model (CCM), which include decision support, provider feedback, self-management tools and resources, and linkages to community-based services. DISCUSSION: We hypothesize that practice facilitation will result in superior clinical outcomes compared to usual care; that the effects of practice facilitation will be mediated by greater adoption of system changes in accord with PCMH and CCM; and that there will be increased adaptive reserve and change capacity. TRIAL REGISTRATION: NCT02646488.

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.