Michael McKee, Health Services & Community Partnership Director Mariko Toyoji, Research Administrator International Community Health Services

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1 Michael McKee, Health Services & Community Partnership Director Mariko Toyoji, Research Administrator International Community Health Services

2 THE HIT- B PROJECT: REDUCING HEPATITIS B DISPARITIES THROUGH HEALTH INFORMATION TECHNOLOGY MARCH 6, 2016 MARIKO TOYOJI, MPH RESEARCH ADMINISTRATOR

3 PresentaEon Outline 1. About the HIT- B Project 2. HepaEEs B: An AAPI Health Disparity 3. HIT- B IntervenEon Components 4. Preliminary Results 5. Lessons Learned and other applicaeons

4 HIT- B Project A NaEonal InsEtutes of Health funded community engaged research pilot project to leverage Health InformaEon Technology (HIT) to improve hepaees B screening, vaccinaeon and linkage to care at a Federally Qualified Health Center. Partner organizaeons: AssociaEon of Asian Pacific Community Health OrganizaEons (AAPCHO) InternaEonal Community Health Services (ICHS) Primary InvesEgators: Rosy Chang Weir, PhD (AAPCHO) Michael McKee, M.Ed. (ICHS) Chia Wang, MD (VM/ICHS)

5 Research Partnership AAPCHO ICHS Community Engaged Research Council NaEonal CHC Partners Community Based OrganizaEons Community Health Advocates ICHS Clinical Staff PaEent Advocate

6 Study Sedng: ICHS A Federally Qualified Health Center OrganizaEon providing primary medical, dental, behavioral health and health educaeon services in King County, WA 4 Primary Care Clinics School Based Health Center Mobile Dental Clinic ACRS Primary Care Partnership ICHS Served 21,426 PaEents in % PaEents of Color (84% AAPI) 64% Use interpreter services (46 languages served) 10% Uninsured (27.5% in 2013) 14% Homeless or housing insecure

7 Needs Assessment Findings IdenEfied Barriers: Need for beier, standardized care pathways for HBV Gaps in care for chronic hepaees B paeents Strained work capacity and Eme constraints EHR Alert FaEgue Key ICHS staff recommendaeons: UElize a team based approach in addressing hepaees B dispariees Incorporate hepaees B populaeon health management strategies into exiseng frameworks and workflows Improve systems for HBV care management and follow up

8 IdenEfying HBV Risk with EHR Data Determine HBV status using lab, vaccine and diagnosis data in EHR

9 HIT- B IntervenEons The HIT- B program to develop tools which leverages EHR data provide key hepaees B data to ICHS clinic staff to help address hepaees B dispariees among FQHC paeents through decision support, care coordinaeon and performance feedback. Huddle Sheet (11/2014) Adds HBV status and vaccine informa4on during each visit Provider Dashboard (12/2014) Provides panel level data on HBV screening CHBV Protocols (3/2015) Point of care decision support for CHBV management CHBV PopulaEon Health Management Reports (4/2015) Supports popula4on health management workflows for CHBV

10 Huddle Sheet

11 Monthly Dashboard Reports

12 Chronic HBV Protocol

13 Chronic HBV PopulaEon Health Management Reports

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15 Impact EvaluaEon Measures Inclusion criteria: Study populaeon included paeents ages 18-70, with a medical encounter during the Eme period of interest and were considered at risk for hepaees B by the proxy algorithm. All pregnant paeents were excluded from the analysis. Measure Numerator Denominator TesEng PaEents with a HBsAg lab dated during the Eme period of interest PaEents without previous HBsAg lab in the EHR or CHBV diagnosis prior to the evaluaeon period VaccinaEon PaEents administered at least one dose of vaccine PaEents who had fewer than 3 doses of vaccine and were HBsAg(- ) Linkage to Care Linkage to care was evaluated on 3 measures: HBV DNA ALT within 6 mo of Dx HBV Health educaeon session Diagnosed with CHBV during the Eme period of interest.

16 EvaluaEon Phases Process EvaluaEon Data CollecEon Baseline 4/ /2014 Pre- interveneon data Baseline data for all interveneon components Phase 1: HBV PrevenEon 11/2015-5/2015 Huddle Sheet and Provider Dashboard Metrics: TesEng VaccinaEon Phase 2: Chronic HBV Management 4/2015-9/2015 Chronic HBV Reports and Chronic HBV Guidelines Metrics: Linkage to Care

17 Study PopulaEon Demographics Baseline (n) Baseline(%) Phase 1 (n) Phase 1 (%) Phase 2 (n) Phase 2 (%) N Sex Female % % % Male % % % Ethnicity Chinese % % % Vietnamese % % % Filipino % % % Korean % % % Cambodian % % % *Study PopulaEon included paeents aged with a medical encounter during the Eme period of interest

18 Study PopulaEon Demographics Age Baseline Baseline (%) Phase 1 Phase 1 (%) Phase 2 Phase 2 (%) % % % % % % % % % % % % % % % CHBV Prevalence HBsAg Results NegaEve % % % PosiEve % % % Total Sample CHBV % % % *Study PopulaEon included paeents aged with a medical encounter during the Eme period of interest

19 TesEng Results Percent of eligible pa,ents with HBSAg 35% 30% 25% 20% 15% 10% 5% HBsAg labs during,me periods among adult pa,ents without previous screening or CHBV diagnosis 21.0% 27.9% 28.8% n=739/3526 n=1043/3733 n=1043/3626 0% Baseline (4/ /2014) Interven,on 1 (11/2014-5/2015) Interven,on 2 (4/2015-9/2015)

20 VaccinaEon Results Percent of eligible encounters with hepa22s B vaccina2on Percent administereed vaccine among eligbile pa,ents 30% 25% 20% 15% 10% 5% 12.7% n=124/ % n=293/1073 0% Baseline Phase 1: 11/14-5/15

21 Linkage to Care Outcomes 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Linkage to Care for CHBV Pa,ents 86.7% 81.0% 75.0% 70.0% n= 45/60 n=55/79 n= 55/60 n=64/ % 16.5% n=7/60 n=13/79 HBV DNA ALT in 6 mo Health Ed Baseline: 4/14-10/14 Phase 2: 4/15-9/15

22 ICHS Hepa22s B Popula2on Outcomes % Baseline: 4/14-10/14 Phase 1: 11/14-5/15 Phase2: 4/15-9/15 Current: 10/15-4/16 PERCENT OF PATIENT POPULATION 50% 40% 30% 20% 10% % Chronic Not Immune Immune Unknown HBV Status

23 Process EvaluaEon Summary A team based approach enhanced communicaeon and collaboraeon on hepaees B among clinic staff HepaEEs B informaeon on the huddle sheet was the most widely used interveneon Barriers to adopeon include, issues with data reliability, disagreement with outcome definieons, and variability in pracece. OrganizaEonal growth and personnel changes impacted implementaeon and emphasize need for ongoing training Staff suggeseons: Provide HBV data with less interpretaeon, show dashboard progress over Eme, refine workflows, address EHR data issues, conenue to resource staff training on viral hepaees

24 HBsAg Labs: Present

25 Lessons Learned Site- based champions facilitated interveneon development, adopeon, use and improvement A team based approach was esseneal to program success Developing organizaeonal IT capacity and interdepartmental cooperaeon enhanced program sustainability Phased implementaeon was necessary to match capacity for change Addressing EHR data issues is challenging and resource intensive Insurance status is a key determinant of HBV teseng and ACA inieaeves likely enhanced the impact of the interveneons FQHCs with HIT resources can develop innovaeve tools to leverage their EHR systems to help address health dispariees

26 Steps For ImplementaEon 1. IdenEfy data in your EHR that can be used to assess risk 2. Assess organizaeonal IT capacity, resources and training needs 3. IdenEfy opportuniees in current workflows to provide hepaees B data 4. Develop team- centered interveneons to support HBV risk assessment, decision support, advance planning and care coordinaeon 5. Empower clinical staff at many levels of the health care team opportuniees to take aceon on hepaees B 6. Provide staff evidence- based training on viral hepaees risk, preveneon and chronic disease management, including USPSTF recommendaeons 7. Incorporate health educaeon into your program to empower paeents, families and communiees

27 Other ApplicaEons Perinatal hepaees B teseng and follow up tracking for the birth dose, HBIG, vaccinaeon and post- vaccinaeon serology PopulaEon health management and care coordinaeon for other chronic diseases MulE dose vaccine reminders such as HPV Other preveneve screening tests (CRC, Pap, HCV) Other applicaeons are possible with the expanded colleceon of SDOH data

28 Thank you! Contact: Mariko Toyoji InternaEonal Community Health Services This project was made possible by the generous support of the National Institutes of Health (Grant # 1R24MD008095).