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Opportunities to facilitate community based research through Community Health Center

Tim Long, MD

Andrew Hamilton, RN, BSN, MS

NCRR Meeting May 15, 2007

of Chicago Community Health Services, LLC

What are our goals

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1. Promote community based/translational research

2. Develop an information network that can promote research and facilitate translation of evidence based interventions into practice.

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Potential of HIT enabled translational research

Description of fully functional Electronic Health Record System in a network of Community Health Centers

State of adoption of Electronic Health Records Systems

Synergies of HIT enabled quality and research

Opportunities for translational research enabled by HIT

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Challenges to Research in Clinical Settings

Limited ability to look at population level data to suggest questions

Labor intensity of baseline and study data collection

Inefficiency of subject identification/recruitment Clinical pressures limiting ability of clinicians to

focus on research interventions Limited ability to prompt or support clinicians to

enroll subjects and implement test interventions Logistics limit communication between

academic setting and clinical site/clinicians

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Challenges in the Healthcare Setting

Increasing complexity of Health Care Challenges in coordination/communication

among medical providers and between supportive services and disciplines

Limited time for interactions Difficulty accessing information in

timely/organized fashion for use in decision making at the point of service

Labor intensity limiting population based data to inform system change

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Capabilities of Electronic Record Systems

Basic a storage and retrieval system

VS

Advanced a sophisticated interactive database

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Considerations in implementing higher level functionality

Acceptance of common vision of quality Adoption of evidence based standards against

which to judge care quality Agreement to conform to standardized ways of

recording data

Ability to capture and process relevant data Relevant care elements are captured as

structured information Implies that “order entry” is computerized Data is “clean” and consistent

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What is the Alliance?

BPHC/HRSA funded Network Essentially a joint venture of four

independent organizations with the desire and ability to work together on building some common infrastructure

Ability to access higher quality, efficiency and economy of scale

Dedication to quality Desire to ultimately share with others

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Community Health Centers

first funded by the Federal Government as part of the War on Poverty in the mid-1960s.

designed to provide accessible, affordable

personal health care services for people living in medically underserved communities where economic, geographic, or cultural barriers limit access to primary health care.

Mission encompasses quality, access, and responsiveness to particular needs of the community served.

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principal services include: primary and preventive health care, behavioral health care, outreach, and dental care

ancillary services include: laboratory tests, X-ray,

environmental health, and pharmacy services

related services such as health education, transportation, translation, and legal services

currently more than 900 nationally with presidential initiative to increase number

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Who CHCs Serve

91.1% of clients are below 200% poverty

40.1% are Uninsured 63.5% are Racial/Ethnic minority 726,813 Migrant/Seasonal

Agricultural Workers 703,023 Homeless Clients

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CHC Profile

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o 952 Community-Based Organization

o 1356 Sites of Care across US

o 14.2 Million Patients Served

o 90,000 MDs/NPs, RNs, & Dentists

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Alliance HIT project goals

1. Implement EHRS in a network of Community Health Centers in a manner that ensures consistency and accuracy of health information across all practitioners, sites and populations.

2. Develop a data warehouse that will monitor, aggregate, and provide data to be used for clinical and system quality improvement.

3. Utilize the EHRS/data warehouse to facilitate and encourage the use of evidence-based practice measures at the point of care.

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HIT project goals

4. Utilize the EHRS/data warehouse to facilitate continuous improvement of health care quality and safety and develop its function as a patient registry.

5. Promote and support the realization of the full potential of EHRS use in ambulatory care settings, particularly among safety net providers, to improve health care quality and safety.

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HIT Partnership

American Medical Association Health Information Management Systems

Society GE Healthcare Clinical Data Services First Consulting Group Health Research and Education Trust Funding agencies:

HRSA ◊ AHRQ ◊ Chicago Community Trust ◊ Michael Reese Health Trust ◊ Robert Wood Johnson Foundation

Commonwealth Fund ◊ Illinois Department of Public Health ◊ Chicago Department of Public Health

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Clinical consensus

Chronic Care Model to manage disease and populations of patients.

Network wide clinical standards. Utilize national experts and evidence

based protocols as basis for standards of care.

Utilize internal/local subject matter experts to review standards and support development of the screens.

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Considerations for EHRS development and implementation

Promote use of standardized templates Structured data entry Ease of data entry to encourage providers

to capture needed information as part of care delivery

Mapping of data elements to care protocols Content to include full spectrum of care (eg,

mental health/case management)

Structured Data Entry

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Consideration for Report Development

Competing/Multiple Performance Measurement Sets with unaligned performance measures.

Lack of Clinical Data Standards for many important medical concepts (such as Foot Exam, Pt. Education, etc)

Inconsistent data definitions across EHR Vendors

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Measure Example

Diabetes Measurement Set (foot exam)

o Measure: Percentage of patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam)

Numerator = patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam)

Denominator = All patients with diabetes 18-75 years of age

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Technical SpecificationsNumerator

Patients who received at least one complete foot exam (visual inspection, sensory exam with monofilament, and pulse exam)

Note: All three components must be completed within the reporting period but they do not have to be completed at the same visit.

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Technical SpecificationsDenominator

All patients with diabetes 18-75 years of age

Codes to identify patients with diabetes include: ICD-9-CM Codes: 250, 357.2, 362.0, 366.41,

648.0) (DRGs) 294, 205 Prescriptions to identify patients with

diabetes include: Insulin prescriptions (drug list is available) and

Oral hypoglycemics/ antihyperglycemics prescriptions (drug list is available)

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Technical SpecificationsExclusions

Exclude patients with a diagnosis of polycystic ovaries (ICD-9-CM Code 256.4) who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year.

Exclude patients with gestational diabetes (ICD-9-CM Code 648.8) or steroid-induced diabetes (ICD-9-CM Code 962.0, 251.8) during the measurement year

Patients with bilateral foot/leg amputation ICD-9-CM exclusion codes for 2.9 Foot Exam: 896.2,

896.3, 897.6, 897.7 Other reason documented by the practitioner for

not performing a complete foot exam

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Considerations of Technical Architecture

Hosting in a secure level 3 facility Redundant architecture and secure backup Ability to access system anywhere via

internet Interface engine to build and manage

interfaces Export of data to a data warehouse

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Potential of EHRS & Research

Decision Support Client recruitment Study protocols

Performance Measurement Data collection Study protocols

Remote hosting Communication between study sites Off site intervention

Data warehouse/reporting De-identification of data Aggregation and analysis of data

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Status of System use

Live at main sites of all 4 Health Centers 125 concurrent users, approximately 225

individual users. “Big Bang” - All staff, with full functionality

of the system Productivity at pre-implementation levels Next wave of Alliance sites to go-live

beginning in June Planning implementation at first non-

Alliance sites

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System Use Measures

Adult Use of diabetes disease

management form Use of cardiovascular disease

management form Use of HIV disease management

form Use of Asthma disease management

form Mammogram BIRAD score

documented PAP Results documented Colonoscopy Screening documented

Adolescents Sexual Activity documented at office

visit Violence risk documented at office

visit

Pediatrics Developmental assessment documented Weigh percentile documented Height percentile documented Head circumference percentile

documented

OB/GYN Prenatal visit with documented EDC Prenatal visit with FHR documented Prenatal visit with genetic history

documented

Mental Health Established treatment plan date

documented Treatment plan revision date

documented Signed metal health assessment

documented Substance abuse screening documented

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System Use Measures

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Use of Diabetes Disease Management Forms

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Performance Measures

AMA/HDC Diabetes AMA/HDC CVD HIV/HIVQUAL AMA/HDC Asthma AMA/HDC Preventive Care

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Pre/Post EHRS Go Live Diabetes Data

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Data Warehouse

Login screen

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Alliance Reports Folder

AMA and HDC reports developed

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HDC Diabetes Report

HDC Diabetes measures along left side

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Can Export Report to Excel

File will download locally

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Can Export Report to Excel cont.

Minimal re-formatting, then submit to HDC

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Can Also Drill Down to Patient Detail

Note patient ID is encrypted in Portal Reports

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Can Also Drill Down to Patient Detail cont.

Need to run “Re-ID” macro in Excel to link encrypted patient ID to EHRS patient information

Re-ID will link Pt Name to this #

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Correlation between EHRS elements and research plan

Evidence based practice guideline Research protocolData elements defined Subject criteria, pre and post data elements

End user form designed to provide decision

support at point of patient care Study protocols Measures defined and Data elements mapped

to reports Baseline and study data collection plan

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Benefits of CHC Sector

Representation of disparate populationsComplete spectrum of health servicesStability of service populationQuality orientation – desire to implement

evidence based practice and contribute to improvement

Network infrastructure to support multiple site studies

Experience with HIT

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