November 26 , 2007

Manhattan Project
By Selena Chavis
For The Record
Vol. 19 No. 24 P. 26

A New York City EHR initiative brings together public health and primary care in an effort to improve the quality of care.

It’s an innovative approach to cooperative electronic health record (EHR) implementations that many industry professionals hope will set a new standard for adoption across the nation. As part of a $27 million initiative set into motion by New York City Mayor Michael Bloomberg to improve the quality and efficiency of healthcare, the Primary Care Information Project (PCIP) was recently implemented to support the adoption and use of prevention-oriented EHRs, primarily among community-based primary care physicians who treat the city’s underserved and vulnerable populations.

According to Assistant Commissioner Farzad Mostashari, MD, MSPH, the PCIP was implemented under the New York City Department of Health and Mental Hygiene (DOHMH) and formulated with the foundational understanding that primary care is the critical interface between public health and the healthcare system. It is also based on the theory that the inefficiencies and challenges of healthcare are largely attributable to the overall antiquated and fragmented system that fails to properly collect and use health information.

“It’s a little unusual in that respect. Health departments have not typically taken an active role in EHR projects,” Mostashari notes. “It’s important for health departments to think about how we can work with our medical partners.”

Primary care providers from outpatient practices, including community health centers, correctional facilities at Riker’s Island, and hospital-affiliated outpatient ambulatory care networks, will be the first recipients of the eClinicalWorks EHR software. The initial phase of the project is expected to include a rollout to approximately 1,500 physicians. “Our plan is to do about 100 providers a month,” Mostashari says.

To provide assistance with this undertaking, Massachusetts-based eClinicalWorks—the vendor selected for the project—announced the opening of an office in the city to support the effort. The company signed a $19.8 million deal whereby the city purchases technology licenses and eClinicalWorks manages the deployment. The office will initially be staffed with 30 employees.

“We have started going live already,” says eClinicalWorks President Girish Kumar Navani. “It’s the first time a department of health in this country has done this.”

Gaining Physician Buy-In
After being invited to a presentation on the project, Linda Levy, office manager at Manhattan Family Practice, says the physician group was sold on the initiative. “It was not too little, not too much,” she recalls. “It seemed to fill all of our needs. The software program appealed to us.”

Emphasizing that EHR implementation could have been cost prohibitive for the three-physician practice, she says the sponsorship side of the program was very appealing. “It’s not just the software; it’s the hardware and machinery. … You can’t skimp on that,” Levy says. “You also have the time of implementation where revenues will suffer.”

To qualifying physicians, the program provides state-of-the-art software, two years’ of maintenance and support costs, extensive training for all levels of staff, and interfaces to common laboratory and billing systems, as well as the specific DOHMH Take Care New York (TCNY) customizations, encompassing public health functionalities.

Integrating with the TCNY initiative was an important component of the project, according to Mostashari. The program consists of 10 core health issues determined to have the biggest impact on health but could be prevented by following certain practices. The steps are the following:

1. Having a regular doctor or other healthcare provider;

2. Becoming tobacco-free;

3. Implementing heart-healthy practices;

4. Being aware of HIV status;

5. Getting help for depression;

6. Living free of alcohol and drug dependence;

7. Getting checked for cancer;

8. Obtaining needed immunizations;

9. Creating safe and healthy home environments; and

10. Having a healthy baby.

Since being introduced in 2003, TCNY has successfully increased access to healthcare, reduced smoking rates, increased HIV testing and colon cancer screening, and further reduced childhood lead poisoning and infant mortality rates to historic lows. In fact, the DOHMH reports life expectancy for the average New Yorker is longer than the U.S. average for the first time since World War II.

To meet the requirements for inclusion in the EHR program, primary care practices have to be located in zip codes where large percentages of underserved populations are deemed to exist or maintain a patient load of at least 30% of patients in New York state-funded insurance programs, self-pay, sliding scale, or charity care. Providers are required to participate in the PCIP’s quality improvement efforts, which include automated confidential quality reporting, decision support tools for priority preventive care services, and linkage to public health information systems.

A demonstrated state of readiness is also a prerequisite in that practices must budget $4,000 per provider for the PCIP technical assistance fund, commit time for clinician and staff training, and demonstrate that the needed technical infrastructure is available. Medical practices have to supply computers, a high-speed Internet connection, and IT support staff. For practices unable to meet the technological requirements, state grant programs that provide funding to upgrade medical technology are an option.

Mostashari acknowledges physician buy-in was a concern, and a solid physician outreach and buy-in initiative was implemented early in the process. “We’re doing a series of outreach efforts,” he notes, referring to newsletters, implementation kits, and presentations. “We do door-to-door. Public health staff visited physician offices, especially in areas like Harlem and Brooklyn where there was the largest potential for disease management.”

The results have been promising; Mostashari believes the program’s success will be expanded in the near future.

For Levy, the timing and availability of eClinicalWorks’ expertise was a clear bonus. As the first practice to implement the EHR, Levy says beginning the process in the summer months when business was a little slower helped.

“They sent very good trainers. … They don’t expect you to be computer geeks,” she says, adding that the availability of experts on site helped build confidence throughout the practice and was crucial to success. “The first week, you are torn between loving it and throwing it out the window. The learning curve is huge.”

An Expanded EHR
According to Kumar Navani, the promising piece of this project lies in its potential to raise the bar for what EHRs can accomplish. “It’s not just about implementing an EHR,” he emphasizes. “It’s about improving quality of care.”

Built around the TCNY initiative’s success, the DOHMH collaborated with eClinicalWorks to develop functionalities that would assist ambulatory care providers to better implement solid practices around chronic care and disease management. Specifically, providers would be able to view patient population-level statistics to better target individuals for broad interventions, improve adherence to clinical best practices, and provide interfaces with existing information systems such as the citywide immunization registry and reportable diseases.

The system is able to alert doctors when patients are due for preventive care, prompting the doctor to advise patients. The DOHMH plans to compile the information and tell each practice how it is doing with making sure its patients are receiving appropriate routine care.

“EHRs as currently implemented do not improve quality of care,” Mostashari says, adding that New York City’s EHR implementation offers such features as automated quality areas and decision support for public health issues. “We are trying to change the market here; public health is now a potential customer.”

The project’s vision consists of three concentric circles, Mostashari says, including EHR delivery to eligible physicians, a communitywide quality reporting and quality improvement program, and a health information exchange (HIE).

eClinicalWorks was chosen as the best-of-breed EHR with the understanding that the product would have to be developed in cooperation with the city. “No EHR has the kind of functionality we were looking for,” Mostashari says. By choosing a single vendor, he says the city will make it easier for doctors to share patient information.

Noting that the future of healthcare delivery is moving more toward performance-based structures, Mostashari asserts that “what is exciting about this project is that it will make the offering part of the market.” The expanded EHR will be available in the first quarter of 2008 as a next-generation project.

“Most vendors—including us—have been focusing our efforts around speed,” Kumar Navani says. “The big focus in New York City is the importance of the EHR toward improvement of care. We think this will revolutionize the perception of EHRs.”

As part of the organization’s ongoing development of the product, he adds that plans are underway to further incorporate dashboards into the technology that will give a high-tech overview to physicians in a quick “nuts-and-bolts” format.

“No longer are we trying to sell why physicians need an EHR. … That curve is behind,” Kumar Navani says, suggesting that for many physicians, the role of the EHR is becoming more about improving healthcare.

Levy agrees, adding that many insurance companies are putting parameters in place for measurements and benchmarks. “Any initiative that helps patients get the care they need, we’re very supportive of it,” she says.

Best Practices
According to Mostashari, it was early in the process when the collaborative effort identified that the technology would have to be built around the needs of small physician practices. “The system has to work for them. They are the largest provider group,” he notes. “That has been a really hard nut to crack. We have been focusing on ease of use.”

With privacy concerns looming large, Mostashari acknowledges that the security component was “one of the things that could kill the project.”

Using a federated model in which data is distributed and maintained as “local” as much as possible, Kumar Navani emphasizes that the “data always sit in the institution that supports it.”

The project is not creating a large citywide database of patient information, but Mostashari says they have created one large laboratory interface.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

A Strategy for Excellence
A public health division devoted to electronic health record (EHR) initiatives? It’s definitely a new concept that New York City officials believe will set a precedent when it comes to the application of EHRs and health information exchanges across the nation. Part of the $27 million Primary Care Information Project (PCIP) initiative developed by Mayor Michael Bloomberg’s office, the strategy included the establishment of the New York City Center of Excellence in Public Health Informatics to help identify and conceptualize project needs and set them into motion.

A collaborative effort led by the New York City Department of Health and Mental Hygiene and supported by the Columbia University Department of Biomedical Informatics and the Institute for Urban Family Health, the center focuses on using HIT to meet public health challenges, according to Assistant Commissioner Farzad Mostashari, MD, MSPH.

The organization has been focusing on emerging public health threats such as bioterrorism, pandemic influenza, and antibiotic resistance, as well as existing health threats with the highest burden or preventability, such as chronic diseases, HIV, substance abuse, and mental health.

With current projects that include the “The Model EHR for Public Health” and public health reporting, Mostashari says the center’s overall goals include the development and dissemination of the following:

• a personal health record that incorporates public health priorities and cognitive research to empower patients in improving their preventive care;

• an electronic clinical decision support system that incorporates public health priorities and epidemiologic data to empower clinicians in providing better preventive and acute care; and

• electronic health information exchange from clinical information systems that improves public health surveillance of antibiotic resistance and emerging health issues.

— SC