Institute of Medicine: Linking EHRs to Public Health Departments Michael Buck, PhD Director of Biomedical Informatics April 8, 2014

Actionable Information in NYC: Primary Care Information Project (PCIP) Mission Improve quality of care in medically underserved areas through health information technology “Clinical Action Arm” bureau of the NYC Department of Health and Mental Hygiene Promote new models of care focusing on prevention and public health priorities Develop new tools in population health management Transition providers from paper charts to an EHR Success Over 12,000 providers joined PCIP and the Regional Extension Center (NYC REACH), including more than: 1095 independent practices 63 community health centers 54 hospitals & outpatient clinics Millions of patients 2

Data We receive eClinicalWorks EHR data on 3000 providers, caring for ~1.8 M patients per year, ~350,000 encounters per month, data on 5M+ patients since 2009 Using Medicaid claims data – to analyze and create dashboards to reach non- eClinicalWorks providers Commercial claims data Information We turn raw data into usable, targeted, actionable information and use it to drive public health focused interventions Action Dashboards: over 20,000 sent last year On-site QI: over 4,000 site visits last year PCMH: PCIP sites are 439 out of 1051 total sites in NYS (42%) Pay for Quality Programs: Health eHearts, Health eQuits Community Engagement activities Data -> Information -> Action 3

Infrastructure to Retrieve EHR Data: The Hub Population Health Network 4 “The Hub” allows secure exchange of aggregate data with PCIP practices on the eClinicalWorks EHR  Send out queries  Receive patient counts overnight The Hub currently covers: 700+ practices ~1.8 M patients per year 5 M+ patients since 2009 Buck MD, Anane S, Taverna J, Amirfar S, Stubbs-Dame R, Singer J. The Hub Population Health System: Distributed Ad Hoc Queries and Alerts. J Am Med Inform Assoc. Published Online First: 9 November doi: /amiajnl

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Patient Care-seeking Behavior by Borough 7

Ambulatory ILI Syndromic Surveillance during 2009 H1N1 8 % of Influenza-Like-Illness Visits

Feedback to Providers 9

Proposal: Develop and validate best practices for using data from EHRs for population health surveillance. In partnership with CUNY School of Public Health, the NYC Health Department will create EHR-based estimates and compare them to a “gold standard” 2013 local HANES survey. We will select high performing measures as the basis of the NYC Macroscope EHR surveillance system. 10 The NYC Macroscope Project

Gold Standard: NYC HANES 2013 Partnership with CUNY SPH Representative sample of 1,500 randomly selected New Yorker adults — Household-based sampling — Citywide estimation Detailed health interviews (CAPI, ACASI) Brief physical exam Biological specimen collection (blood, urine) Mental health screening 11

EHR Limitations: Bias and Measurement Error 12

National ONC Standard: Query Health Completed federal initiative to build distributed query capabilities across healthcare IT vendors. New York City/State Depts. of Health completed one of the first pilots of this new national standard across HIE and EHR data sources. 13

CCDA-based Data Model Develop modular, testable portfolio of Query Health standards and specifications that can adopted by the industry, and support key HITECH and govt. priorities Standardize Privacy and Security Reference Implementation Services Vocabularies: SNOMED-CT, LOINC, RxNorm i2b2 The Results New QRDA 2 & 3 The Results New QRDA 2 & 3 PopMedNet Query Health Standards and Reference Implementation Stack Reference Implementation Stack The Question New HQMF The Question New HQMF Query Envelope Privacy Policy Enablement hQuery Standardize Services Standardize Meaning Standardize Structure Sharing Value Sets Klann JG, Buck MD, Brown J, Hadley M, Elmore R, Weber GM, Murphy SN. Query Health: standards-based, cross-platform population health surveillance. J Am Med Inform Assoc. Published Online First: 4 April doi: /amiajnl

NYS DOH NYC PCIP Information Requestors Data Sources Hospital Practice Sends Query to HIE New York Population Health Registry Stage 2 Meaningful Use Proposal Statewide HIE CCDA Repository (SHIN-NY) Statewide HIE CCDA Repository (SHIN-NY) Other Returns Aggregate Results 15

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Literature 1.Klann JG, Buck MD, Brown J, Hadley M, Elmore R, Weber GM, Murphy SN. Query Health: standards-based, cross- platform population health surveillance. J Am Med Inform Assoc. Published Online First: 4 April doi: /amiajnl Kaye K1, Singer J, Newton-Dame R, Shih SC. Health information technology and the primary care information project. Am J Public Health Mar;104(3):e8-9. [Epub 2014 Jan 16]. 3.Wang JJ, Sebek KM, McCullough CM, Amirfar SJ, Parsons AS, Singer J, Shih SC. Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems. Prev Chronic Dis Aug 1;10:E Andrew M. Ryan, Tara F. Bishop, Sarah Shih and Lawrence P. Casalino. Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records. Health Affairs, 32, no.1 (2013): DeLeon SF, Pauls L, Shih SC, Cannell T, Wang JJ. Early Assessment of Health Care Utilization Among a Workforce Population With Access to Primary Care Practices With Electronic Health Records. J Ambul Care Manage Jul-Sep;36(3): Begum R, Smith Ryan M, Winther CH, Wang JJ, Bardach NS, Parsons AH, Shih SC, Dudley RA. Small Practices’ Experience with EHR, Quality Measurement, and Incentives. Am J Manag Care 2013;19(11 Spec No. 10):eSP12- eSP18. 7.Bardach NS, Wang JJ, DeLeon SF, Shih SC, Boscardin WF, Goldman LE, Dudley RA. Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: A randomized trial. JAMA. 2013;310(10): Ancker JS; Singh MP; Thomas R; Edwards A; Snyder A; Kashyap A; Kaushal R. Predictors of success for electronic health record implementation in small physician practices. Appl Clin Inform Jan 16;4(1): Ryan AM, Bishop T,Shih S, Casalino LP. Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records. Health Aff (Millwood) Jan;32(1): Buck MD, Anane S, Taverna J, Amirfar S, Stubbs-Dame R, Singer J. The Hub Population Health System: Distributed Ad Hoc Queries and Alerts. J Am Med Inform Assoc. Published Online First: 9 November doi: /amiajnl Plagianos MG, Wu WY, McCullough C, Paladini M, Lurio J, Buck MD. Syndromic surveillance during pandemic (H1N1) 2009 outbreak, New York, New York, USA. Emerg Infect Dis 2011; 17: Accessed October 5,

Contact Information Michael Buck, PhD Director of Biomedical Informatics 18