Using EHRs for Real-Time Collaboration between Primary Care and Public Health

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1 Using EHRs for Real-Time Collaboration between Primary Care and Public Health Successful Collaboration Between A Community Health Center Network and a Public Health Department Joseph Lurio, MD Michelle Pichardo, MPH

2 The Institute for Family Health 15 Community Health Centers 5 Bronx, 4 Manhattan, 6 Mid-Hudson Valley 8 homeless healthcare sites 1 School based health programs 3 Dental centers 2 Community Mental Health Centers 2 Free Clinics 225,000 primary care visits 70,000 patients

3 The Institute has been fully paperless since September 2002 on Epic Systems (Verona, Wisconsin) Electronic Health Record and Practice Management System In 2007 the Institute doubled in size with the acquisition of the Mid Hudson Family Health Institute. In the first month all 6 sites were live on the PMS. Six months later all sites were fully live on the EHR.

4 Progression of HIT Innovations at the Institute EHR/PMS Implementation Clinical Decision Support Quality Reporting/ Improvement Patient Portal HIE

5 NYC DOHMH Serves all five boroughs of NYC Six Major Divisions Disease Control Environmental Health Epidemiology Health Care Access and Improvement Health Promotion and Disease Prevention Mental Hygiene Staff of 6,000

6 Center of Excellence in Public Health Informatics

7 Project Partners Institute for Family Health NYC DOHMH Columbia University DBMI

8 Goals of Collaboration Improve Function of EHR Demonstrate How CHCs can be integrated into Public Health Infrastructure

9 Collaborative Projects Center of Excellence (2004) TCNY Syndromic Surveillance Immunization Interface (Bidirectional) (NYCDOHMH & IFH) Medlee natural language processing data extraction project (Columbia) New Projects Reportable Disease Notification Real Time, Bi- Directional Alerts SSTI (Appropriate Skin Infection Treatment) Swine Flu Surveillance

10 Syndromic Surveillance Data

11 Take Care New York (TCNY) Goals Have PCP Healthy Heart Diabetes Mellitus: BP/LDL/A1c Cardiac Patients: BP/LDL Cancer Screening Mammo Cervix Colorectal Diabetes Screening Hypertensives Hyperlipidemics HIV Screening Substance Use Assessment (Tobacco, Alcohol, Drugs) Smokers Taking meds Smoker Quit Rate Buprenorphine Treatment Obesity (BMI Assessment and Treatment) Depression Screening Reassessment (Treatment)

12 Percentage of patients ages 65+ who received a flu shot since the most recent September /30 /2006 7/31 /2006 8/31 /2006 9/30 / /31/ /30/ /31/2006 1/31 /2007 2/28 /2007 3/31 /2007 4/30 /2007 5/31 /2007 6/30 /2007 7/31 /2007 8/31/2007 9/30 / /31/ /30/ /31/2007 1/31/2008 2/29 /2008 3/31 /2008 4/30 /2008 5/31 /2008 6/30 /2008 7/31 /2008 8/31 /2008 9/30 / /31/ /30/ /31/2008 1/31/2009 2/28 /2009 3/31 /2009 4/30 /2009 5/31 / ALL Percentage

13 TCNY Integration into Clinical Workflow Strategy: Clinical Alerts (BPAs) with hyperlinked order sets (SmartSets) BPAs Can be set to fire with: Specific chief complaint entered by nurse Diagnosis entered by provider No order for procedure, or filed result within defined look back period Selection Criteria: Age, Gender, Diagnosis, Med.

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15 Example SmartSet

16 Percentage of Women ages that Received a Mammogram ALL 6/30/2006 7/31/2006 8/31 /2006 9/30/ /31/ /30/ /31/2006 1/31/2007 2/28 /2007 3/31/2007 4/30/2007 5/31 /2007 6/30/2007 7/31/2007 8/31/2007 9/30/ /31/ /30/ /31/2007 1/31/2008 2/29/2008 3/31/2008 4/30/2008 5/31/2008 6/30 /2008 7/31/2008 8/31/2008 9/30 / /31/ /30/ /31/2008 1/31/2009 2/28/2009 3/31 /2009 4/30/2009 5/31/2009 Percentage

17 Integrating Public Health Alerts at the Point of Care

18 Rapid Response To Emerging Conditions Objectives: Decrease time to diagnosis Opportunity for clinician to identify and treat rare conditions quickly Increase chances for containing an epidemic

19 Current State of Public Health Information Exchange Health Alert Network (HAN) MMWR Mass media Peer-reviewed literature Problem: Information not integrated into clinical workflow

20 Delivery of Public Health Information via EHRs Enables: Integration of information in the clinical workflow Delivery of information in a specific and contextually relevant manner Collection of additional Patient history Diagnostic tests Up to date treatment (Via guideline transmittal & Linked Order Sets)

21 Legionella Advisory HAN advisory issued for increase in Legionella cases in Bronx 7/24/07 Institute for Family Health placed alert on 7/27/07 Alert triggered 142 pts Acknowledged 5 pts (4%)

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25 E. Coli Alert HAN alert issued for E. coli O157:H7 multistate outbreak 9/28/07 Institute for Family Health placed alert on 10/1/07 Alert triggers: CC of diarrhea or stomachache, or diagnosis of gastroenteritis, diarrhea or bloody stool Alert triggered 287 pts Acknowledged 65 pts (23%)

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28 Testing Performed at Visits /30/2006 1/13/2007 1/27/2007 2/10/2007 2/24/2007 3/10/2007 3/24/2007 4/7/2007 4/21/2007 5/5/2007 5/19/2007 6/2/2007 6/16/2007 6/30/2007 7/14/2007 7/28/2007 8/11/2007 8/25/2007 9/8/2007 9/22/ /6/ /20/ /3/ /17/ /1/ /15/ /29/2007 Date Visits Number Tested

29 Decision Support Public Health Notices (HPN) - Good Best Practice Alerts - Better It was a dark and stormy night. Dr. Lurio s clinic was supposed to be over at 5PM, but at 6 his nurse told him there was one more patient to be seen

30 H1N1 Surveillance Project Using IFH/DOHMH partnership Opportunity to address: Proportion of ILI due to H1N1 swine influenza Frequency of severe illness Differences between mild and severe illness

31 H1N1 Surveillance Project Community surveillance project began on 5/26 Key partners: IFH DOHMH Columbia University Value to public health and clinical community

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33 Alert for Swine Flu

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37 H1N1 Surveillance Project Results to Date 114 patients tested since 5/26 61 (54%) positive for H1N1 Sensitivity of rapid test: 28% (17/61) Number Positive Weekly MassTag PCR Results May 30 June 6 June 13 June 20 Week H1N1 Flu B RSV HPIV HMPV CoV EV/RV

38 Collaboration between DOH and CHC provides mutual Benefit DOH Requires Ambulatory Practices to act as eyes and arms CHCs rely on DOH to provide expert guidance and situational awareness to allow effective health care delivery Electronic Health Records are a communication tool that allows this collaboration to occur.

39 Special thanks to: Frances Morrison 2, Rachel Berg 1, Michael Buck 2, Winfred Wu 3, Kwame Kitson 1 Farzad Mostashari 3, Neil Calman 1 1 Institute for Family Health; 2 Columbia University; 3 New York City Department of Health and Mental Hygiene

40 Contact information: Joseph Lurio, MD Chief Medical Information Officer Phone: Michelle Pichardo, MPH Project Coordinator, HIT Grants Phone: ext.1279