Best Practices in Implementation of Public
Health Information Systems Initiatives to
Improve Public Health Performance: The
New York City Experience
In collaboration with the National Association of County and City Health Officials and the Centers for Disease Control and Prevention, NORC at the University of Chicago is compiling a series of best practice reports highlighting successful practices in public health information systems and health IT on the state and local levels. The findings and conclusions in this document are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. This case study was supported by funds made available from the Centers for Disease Control and Prevention, Office for State, Tribal, Local and Territorial Support, underGrant #3U38HM000449-04S2, CFDA # 93.283.
BACKGROUND
New York City‟s public health system is over 200 years old beginning with the establishment of the New York City (NYC) Board of Health in 1805. In 1870, the NYC Health Department was formed and in 1954 the New York City Community Mental Health Board was created. These events culminated in 2002 with the formation of today‟s New York City Department of Health and Mental Hygiene (DOHMH), which operates as an autonomous agency. The DOHMH has led many national public health efforts, such as the detection of the West Nile virus, and continues to be a leader in health information technology (IT). Two major health IT initiatives, The Primary Care Information Project (PCIP) and the Citywide Immunization Registry (CIR under the Immunization Bureau), focus on working collaboratively with providers who use electronic health records (EHRs), establishing bidirectional exchange, and coordination for health information exchange (HIE). The DOHMH‟s health IT and public health activities are based on the unique needs of NYC‟s population set forth by the Take Care New York (TCNY) health policy, instituted by former Commissioner Dr. Thomas Frieden. TCNY laid out the public health priorities to address the leading causes of preventable illnesses and death among New Yorkers and to improve population health.
NEW YORK CITY’S APPROACH TO HEALTH IT
The TCNY initiative provided an opportunity to operationalize a public health intervention through collaboration with health care practices using health IT. DOHMH‟s approach to health IT involves gaining provider buy-in for expanded EHR adoption and use, implementing EHR functions that support public health and provider activities, and developing innovative approaches to utilize the data received from providers. Accordingly, PCIP provides valuable service to their participating providers around EHR adoption and related supports. As an outcome of their efforts, DOHMH expects an increase in evidence-based clinical preventive services delivered and in the number of NYC residents whose care can be measured through EHR data, the ability to provide actionable information to NYC providers and DOHMH, improved coordination of care, and a reduction in the number of adverse medical events in ambulatory care through the application of best practices.
HEALTH IT STRATEGIES
Primary Care Information Project (PCIP) – Regional Extension Center (REC), Health
Department
In 2005, PCIP was implemented to develop a prevention-focused EHR as well as increase EHR adoption. The PCIP also serves as the NYC Regional Extension Center (REC) called the NYC REACH. PCIP supports over 3,000 providers using the prevention-focused EHR and supports 6,000 providers overall which serve over 2.5 million NYC patients. The PCIP project is based on three overarching goals:
1. Improve physician workflow and care management to optimize use of the EHR.
PCIP selected eClinicalWorks to develop a prevention-focused EHR. The EHR includes standardized clinical data elements, public health-focused clinical decision support and alerts, patient self-management tools, and is able to generate lists and automatically measure clinical quality measures (CQMs).
2. Improve quality in a measurable way through the use of an information system oriented towards prevention.
On a monthly basis PCIP receives aggregated data from the EHRs on over 70 measures (such as utilization, quality, syndromic, etc.) with the quality measures focused on TCNY‟s ten priority areas such as controlled blood pressure, flu shots administered, and diabetes control. In return for adopting EHRs that provide aggregate data to public health, providers receive reports on CQMs which in turn helps them improve the quality of care provided. Another value-add for providers, as a result of PCIP‟s involvement with eClinicalWorks, is enhanced EHR functionality (i.e., querying and interfaces are included without being charged additional fees).
3. Reform reimbursement that rewards providers for effective disease prevention and effective chronic disease management.
The capability for EHRs to exchange data with DOHMH is a major priority to support more effective public health activities and practice-based population health management. PCIP‟s goal is to use this information to support DOHMH and the state partners to identify gaps in care. All three goals are intended to incentivize, rather than burden, providers to participate in HIE aligned with public health Meaningful Use objectives. For example, the PCIP used business and workflow analyses to ensure that EHR functionality integrates well with clinical workflow. According to Winfred Y. Wu, Director of Public Health Informatics at PCIP, “If something doesn‟t integrate well with the workflow, it‟s not going to be well-received.” PCIP Quality Improvement Field Teams work with providers around workflow and to improve EHR use by practice staff. In addition, Field Teams go out in to practitioners‟ offices to provide onsite consultations.
Collaboration between PCIP and the Citywide Immunization Registry (CIR)
PCIP staff is in the process of developing functionality for EHR integration with the CIR. PCIP continues to work with eClinicalWorks to develop a specification guidance document that lays out the uses of a bidirectional interface and how the EHR system should develop functionality that enables seamless integration with clinical workflow. Because updating guidelines and recommendations initially built into the EHR can be costly endeavor, PCIP asked vendors to build a tool that would enable PCIP to complete their own system modifications. PCIP allocated National Public Health Improvement Initiative (NPHII) Component II funding to support successful implementation and integration of IT systems by employing a staff person who works to develop the next generation of tools that will need to be built in to EHRs. NPHII funded staff is also responsible for analyzing data received from providers and providing new population health related queries back to practices. On the CIR side, two full-time staff are dedicated to working with EHR systems and providers to enable data exchange.
Citywide Immunization Registry (CIR)
The CIR has maintained immunization records for the children of NYC since 1997. The current CIR strategy is to improve capturing timely, complete, high quality data from providers and then, in a useful manner, share the information with providers, health plans, and schools. Based on years of experience as an immunization registry, the CIR is leveraging health IT to evolve the capabilities of immunization registry to support vaccination program management. The CIR‟s Vaccines for Children online system has the following functionalities to help ease providers‟ workflow:
Annual online registry;
Individualized recommendations for vaccination orders based on data from CDC‟s VACMAN system and a provider‟s historical ordering counts;
Online vaccines ordering and tracking; and
Provider Quarterly Progress Reports.
To help providers improve immunization coverage rates and account for use of vaccines distributed through the Vaccines for Children (VFC) program, the NYC immunization information system (IIS), the CIR, began sending quarterly feedback reports to all providers in 2006. These reports contain up-to-date coverage rates for the routine childhood series vaccines among two-year-olds. During influenza season, the reports include coverage rates among patients 6 months through 18 years for influenza vaccine, and outside of influenza season, adolescent series coverage rates. The reports not only show providers their coverage rates for the current quarter and the three previous quarters, but also give them a percentile ranking to help them assess their performance relative to their peers in NYC. In addition, every quarter, the reports include a measure for VFC accountability called the Doses Administered Report (DAR). The DAR is calculated by dividing the number of doses reported to the CIR as given to VFC-eligible children by the total number of VFC doses received by the provider. Providers who achieve a DAR above 90% along with a two-year-old coverage rate of 90% or better (80% for adolescent series) are honored at NYC‟s Bureau of Immunization‟s quarterly coalition meetings and are listed on the honor roll on the DOHMH Web site.
Bidirectional HL7 Integration
Providers have been using EHRs to report data to the CIR for many years, but up until recently, have not been able to use their EHRs to retrieve CIR data. The CIR built a Web Service in 2009 in order to facilitate the real-time bi-directional data exchange the CIR had long envisioned. The service allows EHRs and other systems to send data to the CIR, retrieve records from the CIR, and receive clinical decision support in real-time. This bi-directional exchange has resulted in many benefits to providers and hospitals including reduced time spent entering immunization histories into their EHRs, a higher success rate for patient searches (88% using the Web
Service versus 62% using the CIR‟s Online Registry), and more complete and accurate immunization records in their EHRs. Columbia Presbyterian Hospital network, the first hospital system to integrate with the CIR HL7 Web Service, observed a 7 percentage point increase in series coverage among two-year-olds and a 5 and 6 percentage point increase for adolescent Tdap and MCV4 coverage, respectively. The feedback from providers using EHRs with a bi-directional interface to the CIR has been overwhelmingly positive, and increasing the number of bi-directional interfaces to NYC providers is one of the CIR‟s key goals for 2012.
Integration with NYC Department of Education (DOE)
Another opportunity to increase immunization coverage is through integrating the CIR and the NYC Department of Education (DOE) systems. Integrating these systems ensures that NYC public school students are current on immunizations prior to school entry. To increase efficiency and expedite the process of student immunization data collection for the NYC public schools, the CIR partnered with the DOE to integrate the DOE‟s Automate the Schools (ATS) student record system with the CIR‟s HL7 Web Service. Typically, parents submit paper immunization records to schools, which secretaries have to manually enter into the ATS record for each student. In 2011, DOE used the ATS system to automatically query the CIR database and pull immunization records for newly registered students, for 6th graders, and for those students who were not up-to-date with the required immunizations. Over 91% of queries sent from DOE resulted in a matching patient record in the CIR. As of March 2012, a total of 1,173,392 immunizations were imported from the CIR into the DOE system for a total of 168,850 students. This resulted not only in time savings for school secretaries, but also in significant time savings for NYC DOHMH, as the number of schools requiring follow-up for immunization compliance below 95% decreased substantially when compared with the previous year (1024 in Oct 2010 vs. 717 in Oct 2011).
The foundation for systems integration between CIR and the Bureau of Childcare has been facilitated by PCIP‟s previously negotiated HL7 requirements with the EHR vendor.
WHAT HAS BEEN ACCOMPLISHED?
Successes
PCIP and the CIR have a great working relationship as they work towards a common goal of establishing bidirectional exchange between their systems. The CIR benefits from the work PCIP put forth to develop comprehensive EHR vendor contracts that support public health programmatic needs as well as Meaningful Use requirements.
PCIP‟s leadership reported their ability to gain provider buy-in as a key factor to successfully increasing EHR adoption and use in NYC. Because providers were able to interact with PCIP staff to understand the overall public health mission, which was not solely financially driven, collaborative relationships were established. Providers receive support from PCIP staff through onsite consultations (billing and clinical quality specialists), quarterly reports, and benchmarking. As a result, PCIP in their NYC REACH capacity has been successful in engaging 3,000 providers in the project. From a health department standpoint, receiving aggregate data (no patient level information is ever shared) provides timely, actionable data that is beneficial to a number of public health functions. An added benefit of this data exchange is that providers‟ privacy concerns are alleviated because data from their EHR is aggregated then sent to public health. PCIP‟s analysis of aggregate data demonstrated continuous improvement in CQMs; specifically in diabetes and blood pressure control. This level of success achieved through collaboration and coordination between public health and health care translates to “lives saved” and improved health for NYC residents.
The CIR has also been able to improve the quality and timeliness of registry data exchange bi-directionally between providers to public health, and have enhanced the ability to share that data with health plans and the NYC DOE. Feedback from providers using an EHR with a bi-directional interface to the registry has been overwhelmingly positive. The CIR leveraged the opportunities of Health Information Technology for Clinical Health (HITECH) to bolster provider participation in the immunization registry and increase the registry‟s usefulness by implementing additional VFC functions. As an older immunization information system, the CIR coordinates with its state partners to exchange immunization data on children that are immunized or vaccinated outside of their home jurisdiction.
Challenges and Barriers
Both the CIR and PCIP identified sustainability as a challenge to continuing their current projects. PCIP holds weekly meetings to discuss sustainable strategies that will support long-term success of their current projects. For example, the value-added services that providers receive through the PCIP may provide an opportunity for generating revenue.
In spite of the advances in various areas of health IT in NYC, there are non-IT challenges and barriers to achieving the department‟s vision. PCIP‟s success in onboarding many providers to an EHR system is met by challenges to gather quality data through practice staff correctly entering data into their EHR system. Other areas that impact health IT include:
Workflow: If an EHR system places unintentional interruptions into a provider‟s usual workflow he/she may use the EHR in non-standardized ways. This may have implications for data and quality improvement.
Workforce: The private sector offers highly-qualified health IT professionals higher salaries than offered in the health department.
Capacity building: Innovative solutions are often ahead of widely adopted standards.
At present, the CIR is also dealing with the ongoing financial challenge of implementing systems that can be maintained and sustained at a low cost. In addition, as the CIR works to improve data exchange with the state they have encountered interoperability challenges between NYC and the state that are associated different levels of functionality.
Another challenge to the CIR that remains is a legal restriction that prevents the CIR from receiving immunization data from the schools. Under the Federal Educational Rights and Privacy Act (FERPA), schools are not permitted to share immunization information with other entities, including the New York State Immunization Information System, without parental consent. Currently DOE and DOHMH are working together to overcome this barrier and allow for true bi-directional exchange between the CIR and the NYC schools. LESSONS LEARNED
The success of the PCIP staff attributes its success to advocate on behalf of, and supporting health care providers who are adopting and using EHRs. The PCIP leadership recognized that providers are small businesses that often have limited resources to invest in information systems improvement; therefore, they made a concerted effort to reduce the burden of implementing EHRs by taking on activities to support providers through implementation and workflow redesign. They found that completing workflow analysis is critical to ensuring that the newly redesigned workflow supports the best, most efficient way of doing work so that providers are encouraged to use the EHR the right way.
DOHMH also recognizes situations where it may be more appropriate to implement health IT strategies to improve public health infrastructure and capacity that differ from state strategies. However, it is still important for the State of New York and NYC to come together to determine which tasks can best be achieved through coordination and collaboration, particularly pertaining to Meaningful Use. When all parties involved agree that Meaningful Use activities and health IT are not solely about testing and messaging, but can also contribute to improved health outcomes for patients, significant progress in health care and public health can be made. LOOKING FORWARD
PCIP and the CIR plan to continue working on sustainability efforts. PCIP, in particular, is considering how quality metrics can be incorporated in „dashboards‟ generated for providers to give them a better sense of how they are performing at the practice level. While one of the CIR‟s key goals for 2012 is to increase the number of bi-directional interfaces available to NYC providers and hospitals. Additionally, based on past experiences, the CIR learned that it can be difficult to make changes to reflect updated immunization schedules once an EHR has been implemented. In an approach to identify sustainable solutions, both programs are considering open source options, when possible, due to the high costs of implementing and maintaining proprietary health IT systems.
ADVICE FOR HEALTH DEPARTMENTS
Foster relationships with healthcare providers by identifying their needs and offering assistance in order to gain their support and participation in HIE.
Engage in conversations with your REC to identify synergies and opportunities to best support Meaningful Use related activities. This may be a way for public health to promote the importance of sharing data that Meaningful Use captures to assess the health of the community and measuring quality metrics.
Identify technological solutions that optimize opportunities to increase intergovernmental agency and private sector cooperation.
Build upon past successes and leverage relationships to design health IT solutions that address multiple data user needs (e.g., the CIR provides immunization information for the school system).
FOR MORE INFORMATION
New York City Department of Health and Mental Hygiene:
www.nyc.gov/html/doh/html/home/home.shtml
NYC DOHMH Primary Care Information Project:
www.nyc.gov/html/doh/html/pcip/pcip.shtml
NYC DOHMH Citywide Immunization Registry:
www.nyc.gov/html/doh/html/cir/cir-home.shtml
NORC at the University of Chicago completed this work on behalf of the National Association of County and City Health Officials (NACCHO) with funding from the U.S. Centers for Disease Control and Prevention (CDC) (under cooperative agreement U38/HM000449-03). We would like to acknowledge the contributions of staff at the New York City Department of Health and Mental Hygiene with whom we spoke.
For additional information about this project, please contact Alana Knudson, PhD, at NORC at the University of Chicago ([email protected]) or Michelle Chuk Zamperetti at NACCHO ([email protected]).
