Case Overview: New York City Electronic Health Record (EHR) Implementation

Source: NYC Tourist

Laura PitarysKeio UniversityMarch 11, 2014

Main PointsThe New York City EHR program’s success:

1. Targeted approach2. Strong government support in

implementation and funding3. Public Health objectives4. Transparency in results5. Innovative pilots

AgendaNYC Health Policy Overview Primary Care Information Project (PCIP)

OverviewPCIP Mission and ObjectivesAddressing Privacy and Security IssuesPCIP Funding and FinancingEvaluations, Results and ChallengesLooking Forward/Next Steps

Hurricane Sandy: October 29, 2012

Source: New York Daily News

Source: NYC DOHMH

$50B damage in the US117 lives lostSources: CDC and NHC

New York City Health Policy Environment

Health Snapshot

Population

• Roughly 8.3M residents in 2012

Poverty

• 21.2% of New York City residents fall under the poverty line in 2012.

Sources: NYC Department of City Planning,, NY Times, United Hospital Fund and NYC DOHMH.

Health Snapshot

Medical Access

• Approximately 1.2M uninsured in NYC in 2009

Health

• 650,000 NYers have diabetes and another 1M are pre-diabetic.

• 15.5% of adults smoke.

Sources: NYC Department of City Planning,, NY Times, United Hospital Fund and NYC DOHMH.

Medically Underserved Areas in NYC

Sources: US Dept. of Health and Human Services and New York World

NYC Primary Care Information Project Overview

Terms• New York City Department of

Health and Mental Hygiene• Municipal public health agency

funded by tax payers

NYC DOHM

H

• Primary Care Information Project

• EHR program managed by DOHMH

PCIP

Terms

• EHR software vendor selected by DOHMH

eClinical-Works

• Regional Healthcare Information Organization

• Collaborative groups of providers working on EHR interoperability.

RHIO

Terms, cont.

• Health insurance for elderly Americans

Medicare

• Health insurance for low income Americans

Medicaid

Terms, cont.• System that has the ability to

connect/interact with other systems (e.g. EMR, pharmacy, lab, other EHR, etc.)

EHR

• Interface that allows patients to view their own medical data and add/modify some data.

PHR

Background

Program ObjectiveAddresses Public Health Concerns

Timeline2005-present

Policy AdvocatesMayor Bloomberg and Commissioner Frieden

ProjectPrimary Care Information Project

SponsorNYC Department of Health

Criteria: The Key to PCIP is Point of Care & Preventive Care

Outpatient Inpatient

Diagnosis

Criteria: Those most in need of medical care

Requirement: Primary Care providers (outpatient)

Serving low income neighborhoods, or

Minimum 10% Medicaid (or uninsured patients), and

Correctional Health facilities (e.g. Rikers Island jails)

Public Policy ObjectivesPCIP was intended to help improve

preventative care, particularly those at risk for chronic diseases.

Areas of health policy concern in NYC include: obesity, Type II diabetes, cardiovascular health, high blood pressure and smoking cessation.

Public Policy Objectives

The PCIP metrics were aligned with the public health Take Care New York (TCNY) core areas (strategic health policy priorities).

TCNY

PCIP

• Quality health care for all

• Be tobacco free

• Be heart healthy

• Healthy neighbor-hoods

• Exercise & healthy eating

• Stop the spread of HIV & STIs

• Recognize & treat depression

• Reduce alcohol & drug use

• Prevent & detect cancer

• Raise healthy children

Take Care

New York

2012

Priorities

EHR ImplementationNYC Dept. of Health (DOHMH) chose one

EHR vendor for implementation.

eClinicalworks, the selected vendor, had a successful track record when Massachusetts providers were given an option in the Mass. EHR initiative.

EHR Implementation

Source: IDC Health IT Strategy 2012

Small Practice EHR

Vendors

Hospitals, Clinics, other care facilities(connected through RHIOs)

Specialists (including behavioral health)

Primary Care Providers for Medically Underserved

(including Correctional Health facilities)

Evolution of EHRs

NYC PCIP Mission and Objectives

24

System reads patient data and gives providers suggested interactions or potential at-risk for chronic disease.

Ability to aggregate data to evaluate the quality of preventive care as well communicable disease outbreaks.

Patients are able to see lab results, prescriptions and make appointments and communicate with doctor online.

Patient Centered Approach

Clinical Decision Support

Clinical Quality Improvement

PCIP Mission

EHR Capabilities

PCIPPatient(PHR)

Pharmacy Labs

Provider

EHR Capabilities

PCIPPatient(PHR)

Pharmacy Labs

Primary ProviderHospitals /

Specialists

EHR Capabilities

EHR

EMR

PHR

Labs

Rx

PM

Claim

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Patients are able to see lab results, prescriptions and make appointments and communicate with doctor online.

Patient Centered Approach

Patient Centered Approach

Patients are encouraged to educate themselves about their health and actively manage any conditions.

Email communication with doctors is enabled as are scheduling capabilities and prescription refill requests.

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Patient PortalAccount Information Intake Forms Messages

Appointments Reminders

Requests Medical Records Education Materials

30

Patient Portal Snapshot

31

Patient Portal Snapshot

32

Patient Portal Snapshot

33

Ability to aggregate data by clinic/hospital to evaluate the quality of preventive care as well communicable disease outbreaks.

Clinical Quality Improvement

Clinical Quality Improvement

Pay-for-performance (P4P) based on effective utilization of the system

Medicine recall alerts: Alerts sent from the Department of Health to providers through EHR system.

34

Clinical Quality Improvement

Comparative dashboard reports available to clinicians by PCIP.

No identifiable patient data is transmitted to the Dept. of Health!

35

Dashboard

Source: DOHMH

36

Dashboard Details

Source: DOHMH

37

System reads patient medical history and data and gives medical providers suggested interactions or potential at-risk for chronic disease.

Clinical Decision Support

Clinical Decision Support System (CDSS)

Based on clinical and demographic information entered (e.g. patient with chronic disease), the system requires prompts for additional questions/information.

The system stores the answers to prompted questions, lab results, prescription information and vital signs.

Alerts for missing data.

Clinical Decision Support

An example of the parameters for Type II diabetics is: At least 18 years of age and Body Mass Index of > 25, > 22 if Asian and Pre-diabetes diagnosis (i.e., fasting plasma

glucose: 100-125 mg/dL, oral glucose tolerance test: 140-199mg/dL, or A1C: 5.7-6.4%)

Source: NYC Department of Health and Mental Hygiene

EHR Results & Effectiveness

Source: NYC Department of Health and Mental Hygiene

EHR Results & Effectiveness

Source: NYC Department of Health and Mental Hygiene

NYC PCIP: Issues of Privacy and Security

Privacy Issues• Health Insurance Portability

and Accountability Act of 1996 (Federal Law)

• Sets national standards for patient security/privacy

HIPAA

• Health Information Technology for Economic and Clinical Health Act (2009)

• Funding for EHR adoption and breach laws

HITECH

Privacy Issues

HIPAA / HITECH

Admin. Simplifica

tion

PrivacySecurity

Enforcement

Brea

ch N

otific

ation

New York State Public Health Law also has its own provisions on patient privacy.

Privacy Law Impacts on EHRExamples of EHR privacy/security setting

from PCIP.Session Time-Out Authentication Lock-

Out

Alpha-Numeric Passwords

Minimum Length Passwords

Source: New York City DOHMH.

Privacy Law Impacts on EHR, Cont.

Examples of EHR privacy/security setting from PCIP.

Audit Trails Role-based access

Patient ability to opt-in/out of HIE Data security policies

Source: New York City DOHMH.

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Privacy EnforcementFines

Monetary Fines of $100 - $50,000 per violation

Annual Max

Maximum calendar year penalty is $1.5M

Prevention

Education and training on HIPAA & HITECH rules, appropriate EHR uses.

Data breaches of 500+ must be reported to media outlets and affected patients.

Electronic Consent Forms

Source: Housing Works.

Practices are able to customize the content of the Practice

Consent Form.

In New York, a patient must opt-in and actively consent to care.

NYC PCIP: Funding and Financing

Subsidies: How much and from whom?

Funding Source PurposeCity Tax Levy Start-Up; implementation; software and hardware

State Interoperability and EHR extension

Federal “Stimulus” funds for interoperability & EHR usage

Private P4P; evaluations; extension pilots

Medicaid / Medicare

Incentives and penalties for meaningful use of EHR

Other Funds that did not make is into the City coffers, but that are used to support regional EHR implementation (e.g. State funds, RHIOs, etc.)

The original funding for PCIP was City Tax Levy ($30M).

Who pays for what?Item PCIP ProviderInitial Hardware √Initial Software √Implementation Support, Training

√

On-going Software fees

√

On-going maintenance

√

Internet connections

√

Replacement hardware

√

Patients pay nothing for the system or access to the patient portal

Providers pay a $4,000 contribution to offset the costs of implementation and training.

NYC PCIP: Results, Challenges and Achievements

EHR Results & Effectiveness

54 Clinics

63 Community Health Centers

31 Large

Practices

1,064 Small Practices

Source: NYC Department of Health and M

ental Hygiene

Over 4 Million Patients

Over 9,000 providers

Note: 3,200 providers and 3+ million patients through initial PCIP program. Extension programs have reached additional providers.

EHR Results & Effectiveness

Source: NYC Department of Health and Mental Hygiene

NYC EHR: Moving Forward

EHR

EMRPH

R

Labs

Pharmac

y

PM Claims

EHR

EMRPHR

Labs

Pharmacy

PM Claims

EHR

EMRPH

R

Labs

Pharmacy

PM Claims

Interoperable Technology (RHIOs/CCR)

CCR (XML format): Header Patient Identifying Information Patient Financial and Insurance

Information Health Status of the Patient Care Documentation Care Plan Recommendation

EHR InteroperabilityPatient Matching done by: Name DOB Gender RHIOs have internal unique

identifiers within their systems

EHR Next Steps Macroscope Pilot: Using aggregate EHR data to

track chronic diseases in real time and allow policy makers to react more quickly to changes trends.

PEEK (Patient Education and Engagement Kiosk) Pilot: Tablets in waiting rooms for patients to access PHRs and educational information.

Follow-up calls to patients who have certain conditions and have not seen a doctor in the recommended timeframe

Success Factors and Challenges

Success

Pay For Performance Incentives

Implementation support and training

Funding to offset risk

Commitment from government

Transparent Results

Success Factors and Challenges

Challenges

Interoperability

Expanding network

Maintaining Data Integrity

Sample Data and Population

“ . . . Ensuring every New Yorker, regardless of income, has access to best healthcare possible. We really can make a difference if we work together.”

- Mayor Michael Bloomberg, 2013

Photo: Harvard Magazine

Thank you