Using a Customer Relationship Management System to Manage a Quality Improvement Intervention.

HealthyHearts New York City (HHNYC), one of 7 cooperatives funded through the Agency for Healthcare Research and Quality's EvidenceNOW initiative, evaluated the impact of practice facilitation on implementation of the Million Hearts guidelines for cardiovascular disease prevention and treatment. Tracking the intervention required a system to facilitate process data collection that was also user-friendly and flexible. Coupled with protocols and training, a strategically planned and customizable customer relationship management system (CRMS) was implemented to support the quality improvement intervention with 257 small independent practices. Features of the CRMS and implementation protocols were customized to optimize program management, practice facilitation tracking and supervision, and data collection for performance feedback to practices and research. The CRMS was a valuable tool for tracking and managing the intervention systematically. Successful implementation of the HHNYC protocol also required an articulated implementation plan and adoption process.

Attributes of High-Performing Small Practices in a Guideline Implementation: A Multiple-Case Study.

OBJECTIVE: HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. METHODS: A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. RESULTS: Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. CONCLUSIONS: These attributes may be important determinants of high performance, indicating not only a small practice's capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.

Patient-Centered Care in Small Primary Care Practices in New York City: Recognition Versus Reality.

BACKGROUND: The Primary Care Information Project (PCIP) is a program administered by the New York City Department of Health and Mental Hygiene to help primary care providers adopt a fully functional electronic health record (EHR) and focus on population health. PCIP also offers practices assistance with the National Committee for Quality Assurance (NCQA) patient-centered medical home (PCMH) recognition application. The objectives of this study were to assess the presence of key dimensions of PCMH among PCIP practices with 5 or fewer providers and to determine whether and to what extent NCQA recognition was related to the presence of these dimensions. METHODS: Analyses relied on data collected from a comprehensive practice assessment survey of PCIP practices administered in summer 2012. The survey was developed to assess discrete dimensions of the PCMH model and other practice characteristics. The study population includes practices for which survey results were available among PCIP practices with 5 or fewer providers (63% response rate; n = 83). RESULTS: At the time of survey, 57% of practices had received some level of NCQA recognition (n = 47). Practices with recognition scored significantly higher on several dimensions, including whole person orientation, team-based care, care coordination and integration, and quality and safety. CONCLUSIONS: Results indicate that very small urban practices in New York City are implementing many key features of PCMH. In general, practices with NCQA recognition scored higher on PCMH constructs and domains relative to practices without recognition; however, there is room for improvement on construct and domain scores in both groups.

A Randomized, Controlled Trial of a Shared Panel Management Program for Small Practices.

OBJECTIVES: To determine whether a shared panel management program was effective at improving quality of care for patients with uncontrolled chronic disease. DATA SOURCES: Data were extracted from electronic health records. STUDY DESIGN: Randomized controlled trial of a panel management program initiated by New York City Department of Health and Mental Hygiene. Patients from 20 practices with an uncontrolled chronic disease and a lapse in care were assigned to the intervention (a phone call requesting that the patient schedule a physician appointment) or usual care. Outcomes were visits to physician practices, body mass index measurement, blood pressure measurement and control, use of antithrombotics, and low-density lipoprotein measurement and control. PRINCIPAL FINDINGS: Panel managers were able to successfully speak with 1,676 patients (14.7 percent of the intervention group). There were no significant differences in outcomes between the intervention and usual care groups. Successfully contacted patients were more likely to have an office visit within 1 year of randomization (45.6 percent [95 percent CI: 22.8, 26.9] vs. 38.1 percent [95 percent CI: 36.8, 39.3]) and more likely to be on antithrombotics (24.4 percent [95 percent CI: 17.7, 31.0]) versus those in the usual care group (17.0 percent [95 percent CI: 13.9, 20.0]) but had no other difference in quality. CONCLUSIONS: A shared, low-intensity panel management program run by a city health department did not improve quality of care for patients with chronic illnesses and lapses in care.

Effect of Physician Participation in a Multi-element Health Information and Data Exchange Program on Chronic Illness Medication Adherence.

BACKGROUND: The Primary Care Information Project (PCIP) includes a network of more than 10,000 physicians across New York City focusing on improving the quality of patient care through the use of health information technology and data exchange. METHODS: We assessed adherence, defined as the percentage with a medication possession ratio (MPR) ≥80%, across 2 time periods for union members whose primary care providers participated in the PCIP compared with those whose providers did not participate. Using prescription claims data from 2008 and 2011, the MPR was calculated for disease-specific categories of drugs among patients with diabetes, hypertension, and both conditions. RESULTS: Greater improvements in the number of adherent members were observed for the PCIP patients with diabetes who were taking diabetes-specific medications (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.08-3.83 for PCIP, versus OR, 1.14; 95% CI, 0.81-1.60 for non-PCIP) and patients with diabetes who are taking lipid-controlling medications (OR, 1.64; 95% CI, 0.73-3.65 for PCIP versus OR, 0.85; 95% CI, 0.55-1.32 for non-PCIP). However, the magnitude and significance of these associations were diminished when practices providing reduced prescription co-pays were excluded from the analyses. CONCLUSION: Access to primary care providers participating in a public health initiative was associated with some improvement in medication adherence. However, reducing prescription co-pays may be a stronger factor for higher medication adherence among union members.

Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians.

PURPOSE: Health information technology (IT) offers promising tools for improving care coordination. We assessed the feasibility and acceptability of 6 proposed care coordination objectives for stage 3 of the Centers for Medicare and Medicaid Services electronic health record incentive program (Meaningful Use) related to referrals, notification of care from other facilities, patient clinical summaries, and patient dashboards. METHODS: We surveyed physician-owned and hospital/health system-affiliated primary care practices that achieved patient-centered medical home recognition and participated in the Meaningful Use program, and community health clinics with patient-centered medical home recognition (most with certified electronic health record systems). The response rate was 35.1%. We ascertained whether practices had implemented proposed objectives and perceptions of their importance. We analyzed the association of organizational and contextual factors with self-reported use of health IT to support care coordination activities. RESULTS: Although 78% of the 350 respondents viewed timely notification of hospital discharges as very important, only 48.7% used health IT systems to accomplish this task. The activity most frequently supported by health IT was providing clinical summaries to patients, in 76.6% of practices; however, merely 47.7% considered this activity very important. Greater use of health IT to support care coordination activities was positively associated with the presence of a nonclinician responsible for care coordination and the practice's capacity for systematic change. CONCLUSIONS: Even among practices having a strong commitment to the medical home model, the use of health IT to support care coordination objectives is not consistent. Health IT capabilities are not currently aligned with clinicians' priorities. Many practices will need financial and technical assistance for health IT to enhance care coordination.

Patient Characteristics Associated With Smoking Cessation Interventions and Quit Attempt Rates Across 10 Community Health Centers With Electronic Health Records.

OBJECTIVES: We used electronic health record (EHR) data to determine rates and patient characteristics in offering cessation interventions (counseling, medications, or referral) and initiating quit attempts. METHODS: Ten community health centers in New York City contributed 30 months of de-identified patient data from their EHRs. RESULTS: Of 302 940 patients, 40% had smoking status recorded and only 34% of documented current smokers received an intervention. Women and younger patients were less likely to have their smoking status documented or to receive an intervention. Patients with comorbidities that are exacerbated by smoking were more likely to have status documented (82.2%) and to receive an intervention (52.1%), especially medication (10.8%). Medication, either alone (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.5, 2.3) or combined with counseling (OR = 1.8; 95% CI = 1.5, 2.3), was associated with higher quit attempts compared with no intervention. CONCLUSIONS: Data from EHRs demonstrated underdocumentation of smoking status and missed opportunities for cessation interventions. Use of data from EHRs can facilitate quality improvement efforts to increase screening and intervention delivery, with the potential to improve smoking cessation rates.

Quality measure performance in small practices before and after electronic health record adoption.

INTRODUCTION: To date, little research has been published on the impact that the transition from paper-based record keeping to the use of electronic health records (EHR) has on performance on clinical quality measures. This study examines whether small, independent medical practices improved in their performance on nine clinical quality measures soon after adopting EHRs. METHODS: Data abstracted by manual review of paper and electronic charts for 6,007 patients across 35 small, primary care practices were used to calculate rates of nine clinical quality measures two years before and up to two years after EHR adoption. RESULTS: For seven measures, population-level performance rates did not change before EHR adoption. Rates of antithrombotic therapy and smoking status recorded increased soon after EHR adoption; increases in blood pressure control occurred later. Rates of hemoglobin A1c testing, BMI recorded, and cholesterol testing decreased before rebounding; smoking cessation intervention, hemoglobin A1c control and cholesterol control did not significantly change. DISCUSSION: The effect of EHR adoption on performance on clinical quality measures is mixed. To improve performance, practices may need to develop new workflows and adapt to different documentation methods after EHR adoption. CONCLUSIONS: In the short term, EHRs may facilitate documentation of information needed for improving the delivery of clinical preventive services. Policies and incentive programs intended to drive improvement should include in their timelines consideration of the complexity of clinical tasks and documentation needed to capture performance on measures when developing timelines, and should also include assistance with workflow redesign to fully integrate EHRs into medical practice.

Do provider attitudes about electronic health records predict future electronic health record use?

INTRODUCTION: Prior research has shown that provider attitudes about EHRs are associated with successful adoption. There is no evidence on whether comfort with technology and more positive attitudes about EHRs affect use of EHR functions once they are adopted. METHODS: We used data from a survey of providers in the Primary Care Information Project, a bureau of the New York City Department of Health and Mental Hygiene and measures of use from their EHRs. The main predictor variables were scores on three indices: comfort with computers, positive attitudes about EHRs, and negative attitudes about EHRs. The main outcome measures were four measures of use of EHR functions. We used linear regression models to test the association between the three indices and measures of EHR use. RESULTS: The mean comfort with computers score was 2.37 (SD0.53) on a scale of 1-3 with 3 being the most comfortable. The mean positive attitude score was 2.74 (SD 0.40) on a scale of 1-3 with 3 being more positive. The mean negative attitude score was 1.81 (SD 0.54) on a scale of 1-3 with 3 being more negative. Within the first twelve months of having the EHR, 59.5% of visits had allergy information entered into a structured field, 64.8% had medications reviewed, and 74.3% had blood pressured entered. Among visits with a prescription generated, 24.5% had prescriptions electronically. In multivariate regression analysis, we found no significant correlations between comfort with computers, positive attitudes about EHRs, or negative attitudes about EHRs and any of the measures of use. DISCUSSION: Comfort with computers and attitudes about EHRs did not predict future use of the EHR functions. Our findings suggest that meaningful use of the EHR may not be affected by providers' prior attitudes about EHRs.

Designing a quality improvement program with electronic health records: New York City's Health eQuits.

Despite clear recommendations for identifying and intervening with smokers, clinical preventive practice is inconsistent in primary care. Use of electronic health records could facilitate improvement. Community health centers treating low-income and Medicaid recipients with greater smoking prevalence than the general population were recruited for a pilot program. Key design elements used to engage centers' participation include designating a project champion at each organization, confirming ability to transmit data for reporting and participation, and offering money to facilitate initial engagement; however, financial incentives did not motivate all organizations. Other methods to elicit participation and to motivate practice change included building on centers' previous experiences with similar programs, utilizing existing relationships with state cessation centers, and harnessing the "competitive" spirit-sharing both good news and areas for improvement to stimulate action. These experiences and observations may assist others in designing programs to improve clinical interventions with smokers.

Randomized controlled trial of biofilm antimicrobial susceptibility testing in cystic fibrosis patients.

This study aimed to determine whether antimicrobial susceptibility testing of Pseudomonas aeruginosa grown as a biofilm, rather than planktonically, improves efficacy of antibiotic treatment for pulmonary exacerbations. This was a multicenter randomized, double-blind controlled trial of 14 days of intravenous antibiotic treatment for pulmonary exacerbations chosen based on conventional vs. biofilm antimicrobial susceptibility results in CF patients with chronic P. aeruginosa infection. There were 74 exacerbations in 39 patients. A total of 46% (12/26) exacerbations in the conventional group compared to 40% (19/48) exacerbations in the biofilm group achieved a ≥3 log drop in P. aeruginosa sputum density (difference -0.03, 95% CI -0.5 to 0.4, p=0.9). Lung function improvements were similar in both groups. Biofilm antimicrobial susceptibility testing did not lead to improved microbiological or clinical outcomes compared to conventional methods in the treatment of pulmonary exacerbations in CF patients with chronic P. aeruginosa.

Increases in smoking cessation interventions after a feedback and improvement initiative using electronic health records -- 19 community health centers, New York City, October 2010-March 2012.

Quitting smoking substantially reduces smokers' risk for smoking-related morbidity and mortality and can increase life expectancy by up to a decade. Most smokers want to quit and make at least one medical provider visit annually. Health care providers can play an important role in helping smokers quit by documenting patients' tobacco use, advising smokers to quit, and providing evidence-based cessation treatments or referrals for treatment, but many providers and practices do not regularly take these actions. Systems to increase provider screening and delivery of cessation interventions are available; in particular, electronic health records (EHRs) can be powerful tools to facilitate increased cessation interventions. This analysis reports on an EHR-based pay-for-improvement initiative in 19 community health centers (CHCs) in New York City (NYC) that sought to increase smoking status documentation and cessation interventions. At the end of the initiative, the mean proportion of patients who were documented as smokers in CHCs had increased from 24% to 27%, whereas the mean proportion of documented smokers who received a cessation intervention had increased from 23% to 54%. Public health programs and health systems should consider implementing strategies to equip and train clinical providers to use information technology to increase delivery of cessation interventions.

Factors related to clinical quality improvement for small practices using an EHR.

OBJECTIVE: To analyze the impact of three primary care practice transformation program models on performance: Meaningful Use (MU), Patient-Centered Medical Home (PCMH), and a pay-for-performance program (eHearts). DATA SOURCES/STUDY SETTING: Data for seven quality measures (QM) were retrospectively collected from 192 small primary care practices between October 2009 and October 2012; practice demographics and program participation status were extracted from in-house data. STUDY DESIGN: Bivariate analyses were conducted to measure the impact of individual programs, and a Generalized Estimating Equation model was built to test the impact of each program alongside the others. DATA COLLECTION/EXTRACTION METHODS: Monthly data were extracted via a structured query data network and were compared to program participation status, adjusting for variables including practice size and patient volume. Seven QMs were analyzed related to smoking prevention, blood pressure control, BMI, diabetes, and antithrombotic therapy. PRINCIPAL FINDINGS: In bivariate analysis, MU practices tended to perform better on process measures, PCMH practices on more complex process measures, and eHearts practices on measures for which they were incentivized; in multivariate analysis, PCMH recognition was associated with better performance on more QMs than any other program. CONCLUSIONS: Results suggest each of the programs can positively impact performance. In our data, PCMH appears to have the most positive impact.

Patient-centered medical home and quality measurement in small practices.

OBJECTIVES: To assess performance on quality measures among small primary care practices that recently adopted an electronic health record (EHR), and how performance differs between practices that have achieved patient-centered medical home (PCMH) recognition and those that have not. STUDY DESIGN: Retrospective cohort study. METHODS: Comparison of practice characteristics and performance on quality measures across 150 independent practices from 2009 to 2011 by recognition status for Physician Practice Connections-PCMH. RESULTS: PCMH-recognized practices performed significantly better than nonrecognized practices on 5 out of 7 clinical quality measures at baseline, and the differences were maintained over the 2-year study period. Both groups improved on all clinical quality measures. Though the magnitude of differences was small, PCMHrecognized practices had a higher number of patients diagnosed with hypertension and proportionally more black patients. A significant difference in PCMH-recognized practices is that they received, on average, 4 additional quality improvement visits compared with nonrecognized practices. CONCLUSIONS: Among small practices that have adopted EHRs, practices with PCMH recognition consistently outperformed practices without recognition on most clinical quality measures. With adequate assistance, small, resource-strapped practices can continue to have higher performance on clinical quality measures.

Perceptions of genetic testing for personalized nutrition: a randomized trial of DNA-based dietary advice.

BACKGROUND/AIMS: Direct-to-consumer (DTC) genetic tests have facilitated easy access to personal genetic information related to health and nutrition; however, consumer perceptions of the nutritional information provided by these tests have not been evaluated. The objectives of this study were to assess individual perceptions of personalized nutrition and genetic testing and to determine whether a personalized nutrition intervention modifies perceptions. METHODS: A double-blind, parallel-group, randomized controlled trial was conducted among healthy men and women aged 20-35 years (n = 138). Participants in the intervention group (n = 92) were given a report of DNA-based dietary advice and those in the control group (n = 46) were given a general dietary advice report. A survey was completed at baseline and 3 and 12 months after distributing the reports to assess perceptions between the two groups. RESULTS: No significant differences in perceptions of personalized nutrition and genetic testing were observed between the intervention and control group, so responses of both groups were combined. As compared to baseline, participant responses increased significantly toward the positive end of a Likert scale at 3 months for the statement 'I am interested in the relationship between diet and genetics' (mean change ± SD: 0.28 ± 0.99, p = 0.0002). The majority of participants indicated that a university research lab (47%) or health care professional (41%) were the best sources for obtaining accurate personal genetic information, while a DTC genetic testing company received the fewest selections (12%). Most participants (56%) considered dietitians to be the best source of personalized nutrition followed by medical doctors (27%), naturopaths (8%) and nurses (6%). CONCLUSIONS: These results suggest that perceptions of personalized nutrition changed over the course of the intervention. Individuals view a research lab or health care professional as better providers of genetic information than a DTC genetic testing company, and registered dietitians are considered to be the best providers of personalized nutrition advice.

The intended and unintended consequences of quality improvement interventions for small practices in a community-based electronic health record implementation project.

BACKGROUND: Despite the rapid rise in the implementation of electronic health records (EHR), commensurate improvements in health care quality have not been consistently observed. OBJECTIVES: To evaluate whether the implementation of EHRs and complementary interventions-including clinical decision support, technical assistance, and financial incentives-improved quality of care. RESEARCH DESIGN: The study included 143 practices that implemented EHRs as part of the Primary Care Information Project-a long-standing community-based EHR implementation initiative. A total of 71 practices were randomized to receive financial incentives and quality feedback and 72 were randomized to feedback alone. All practices received technical assistance and had clinical decision support in their EHR. Using data from 2009 to 2011, we estimated measure-level fixed effects models to evaluate the association between exposure to clinical decision support, technical assistance, financial incentives, and quality of care. Associations were estimated separately for 4 cardiovascular measures that were rewarded by the financial incentive program and 4 measures that were not rewarded by incentives. RESULTS: Financial incentives for quality were consistently associated with higher performance for the incentivized measures [+10.1 percentage points at 18 mo of exposure (approximately +22%), P<0.05] and lower performance for the unincentivized measures [-8.3 percentage points at 12 mo of exposure (approximately -20%), P<0.05]. Technical assistance was associated with higher quality for the unincentivized measures, but not for the incentivized measures. CONCLUSIONS: Technical assistance and financial incentives-alongside EHR implementation-can improve quality of care. Financial incentives for quality may not result in similar improvements for incentivized and unincentivized measures.

Does it get easier to use an EHR? Report from an urban regional extension center.

BACKGROUND: Little is known about whether more experience with an electronic health record (EHR) makes it easier for providers to meaningfully use EHRs. OBJECTIVE: To assess whether the length of time that small practice providers have been using the EHR is associated with greater ease in performing meaningful use-related tasks and fewer EHR-related concerns. DESIGN/PARTICIPANTS: We administered a web-based survey to 400 small practice providers in medically underserved communities in New York City participating in an EHR implementation and technical assistance project. We used logistic regression to estimate the association between the length of time a provider had been using the EHR (i.e., "live") and the ease of performing meaningful use-related tasks and EHR-related concerns, controlling for provider and practice characteristics. KEY RESULTS: Compared to providers who had been live 6 to 12 months, providers who had been live 2 years or longer had 2.02 times greater odds of reporting it was easy to e-prescribe new prescriptions (p < 0.05), 2.12 times greater odds of reporting it was easy to e-prescribe renewal prescriptions (p < 0.05), 2.02 times greater odds of reporting that quality measures were easy to report (p < 0.05), 2.64 times greater odds of reporting it was easy to incorporate lab results as structured data (p < 0.001), and 2.00 times greater odds of reporting it was easy to generate patient lists by condition (p < 0.05). Providers who had been live 2 years or longer had 0.40 times lower odds of reporting financial costs were a concern (p < 0.001), 0.46 times lower odds of reporting that productivity loss was a concern (p < 0.05), 0.54 times lower odds of reporting that EHR unreliability was a concern (p < 0.05), and 0.50 times lower odds of reporting that privacy/security was a concern (p < 0.05). CONCLUSIONS: Providers can successfully adjust to the EHR and over time are better able to meaningfully use the EHR.

Electronic health records and technical assistance to improve quality of primary care: Lessons for regional extension centers.

BACKGROUND: In 2009, the American Recovery and Reinvestment Act apportioned $643 million for a Health Information Technology Extension Program, which established Regional Extension Centers (RECs) to support the implementation and use of electronic health records (EHRs). PROBLEM: Little is known, however, about how RECs should assist in EHR implementation and how they should structure ongoing support. GOALS: The purpose of this paper is to describe physicians' experiences with the Primary Care Information Project (PCIP), an REC run by the New York City Department of Health and Mental Hygiene. STRATEGY: We interviewed 17 physicians enrolled in PCIP to understand the role of the EHRon quality of care and their experience with technical assistance from PCIP. RESULTS: All physicians stated that they felt that the EHR improved the quality of care they delivered to their patients particularly because it helped them track patients. All the physicians found technical assistance helpful but most wanted ongoing assistance months or years after they adopted the EHR.