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                                                               Working Draft - Last Modified 4/3/2009 7:03:42 PM
PCIP- Changing the Quality
Paradigm




                                                               Printed
Presentation
November 7th, 2009




                     Primary Care Information Project   | 0
                                                      DCO-ON0056-20090404-njPP1


AGENDA




                                                                                  Working Draft - Last Modified 4/3/2009 7:03:42 PM
         • PCIP Background

         • The New Federal HIT Agenda




                                                                                  Printed
                                        Primary Care Information Project   | 1
                                                            DCO-ON0056-20090404-njPP1


ON ABCS, USA GETS AN “F”

 • Percentage of Americans at increased risk of heart
   disease that is taking Aspirin – 33%




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 • Percentage of Americans with hypertension that has
   adequately-controlled Blood pressure – 44%

 • Percentage of Americans with high Cholesterol that has
   adequately-controlled hyperlipidemia – 29%




                                                                                        Printed
 • Percentage of American Smokers trying to quit that gets
   help – 20%

Percentage of American GDP spent on health care – 15 %!!

                                              Primary Care Information Project   | 2
                                                                                           DCO-ON0056-20090404-njPP1


MOST AMBULATORY CARE IN THE US IS DELIVERED IN SMALL
PRACTICE SETTINGS, WHERE HIT ADOPTION IS LOW




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  Delivery of ambulatory care in the            Adoption of HIT in Physician
     US by size of practice1                       Practices, by size2
                                                                                                  38
           > 11 physicians
                               1-2 physicians




                                                 Percentage
  6-10 physicians        8 1                                                            27
                                                                              22
               15
                                   44




                                                                                                                       Printed
                                                                        15
                                                                 11


                    32
  3-5 physicians
                                                                 1    2-5    6-15     16-30 > 30
                                                              Number of physicians in a practice



                                                                             Primary Care Information Project   | 3
                                                                                                                            DCO-ON0056-20090404-njPP1

WHEN IT COMES TO PREVENTION, THERE IS ROOM FOR IMPROVEMENT

                             Proportion of Medicare Beneficiaries Receiving
                           Recommended Preventive Services, by Practice Size


               Pneumococcal
                                                   **




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                Vaccination


      Influenza Vaccination                                                                 **             Solo/2-person (1-2)

                                                                                                           Small group (3-10)
                Colon Cancer                                                                               Medium/large group (11+)
                 Screening                         **
                                                                                             ***




                                                                                                                                                        Printed
                Mammograms

             Hemoglobin A1c
               Monitoring                                                                                       ***
      Eye Examinations for
           Diabetics                                                                            *
                                    0         10         20        30        40        50        60        70        80         90      100
                                                        Proportion of Medicare Beneficiaries Receiving Preventive Care, %

                       * P<.05     ** P<.01    *** P<.001
                                                                                                           Primary Care Information Project | 4
 Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of Preventive Services to Older Adults by Primary Care Physicians. JAMA. 2005; 294:473-481.
                                                                                            DCO-ON0056-20090404-njPP1


OUR VISION


                                                   Our Vision

                                             ELECTRONIC




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                                           HEALTH RECORDS
                                              oriented to
                                              prevention


                                                 Healthcare that
                                                maximizes health




                                                                                                                        Printed
                  CARE                                                    PAYMENT
            MANAGEMENT                                              that rewards disease
         & practice workflows to                                    prevention & chronic
           support prevention                                       disease management




       *Frieden TR, Mostashari F. JAMA. 2008 Feb 27;299(8):950-2.             Primary Care Information Project   | 5
                                                                   DCO-ON0056-20090404-njPP1

OVERVIEW OF PCIP
A bureau of NYC DOHMH, founded in 2005
Mission
▪ Improve the quality of care in medically
  underserved areas through health information
  technology (HIT)




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Resources
Current funding:
▪ NY City: $30 million (staff, software, hardware,
  services)
▪ City Council: $6 million (CHC infrastructure)
▪ Clinic/practice contributions: >$15 million
▪ NY State HEAL: $11 million (expansion)




                                                                                               Printed
▪ Federal: $5 million (research and evaluation)
▪ Robin Hood Fund $4-6 million (P4P)
▪ Wellpoint Foundation $500k (software)

Success
▪ ~1600 providers are using the EHR at
   –21 CHCs
   –4 hospital outpatient
   –275 small practices
                                                     Primary Care Information Project   | 6
                                                                          DCO-ON0056-20090404-njPP1


TO GET THE MOST VALUE OUT OF HIT, WE KNEW WE HAD TO STAY
FOCUSED ON THE RIGHT OBJECTIVES



      1. Saving lives
      2. Improving Quality




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      3. Lowering Costs



                  Take Care New York advises that every New Yorker take these
                    10 steps to lead a healthier life:
                  1. Promote Quality Health Care for All




                                                                                                      Printed
                  2. Be Tobacco Free
                  3. Promote Physical Activity and Healthy Eating
                  4. Be Heart Healthy
                  5. Stop the Spread of HIV and Other Sexually Transmitted Infections
                  6. Recognize and Treat Depression
                  7. Reduce Risky Alcohol Use and Drug Dependence
                  8. Prevent and Detect Cancer
                  9. Raise Healthy Children
                  10. Make All Neighborhoods Healthy Places

                                                            Primary Care Information Project   | 7
                                                                                                                        DCO-ON0056-20090404-njPP1

CHOICE ARCHITECTURE- FOCUSING ON WHAT MATTERS MOST

                                 25000
                                                                                     Hypertension
                                                                                     Control


                                                                                                          Hyperlipidemia
                                 20000                                                                    Treatment
    Number of Deaths Prevented




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                                 15000                                                                              Aspirin
                                                                                                                    Prophylaxis




                                 10000
                                                                                                                     Colonoscopy




                                                                                                                                                    Printed
                                 5000
                                                                                                                     Mammography

                                                                                                                           Pneu. & Inf. Vacc.
                                    0                                                                                          Papanicalou
                                     35%   40%   45%   50%      55%     60%    65%     70%    75%   80%   85%     90%      95%
                                                             Percent Eligible Utilizing Service
* Cause-specific model results: estimated number of additional deaths prevented before age 80 by increasing utilization of
selected clinical preventive services to varying levels

* Unpublished data: Farley T., Dalal M., Mostashari F., Freiden T                                         Primary Care Information Project   | 8
                                                                     DCO-ON0056-20090404-njPP1

THE DEAL FOR THE PROVIDERS

     We give them….                   They are responsible for….

    ▪ eCW license                        ▪ Hardware
    ▪ eCW database                       ▪ Staff time spent in
    ▪ 10 days of onsite                      training




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        training                         ▪   Lost revenue
    ▪   Data migration services          ▪   Self-tutorial & web-
    ▪   Business analyst                     based learning
        services                         ▪   $4000 per FTE for
    ▪   Discounted ASP                       Technical Assistance
        services




                                                                                                 Printed
    ▪   Onsite technical
        assistance




 A better deal than Sam’s Club! But still not good enough to get them to
                            meaningful use…
                                                       Primary Care Information Project   | 9
                                                                                   DCO-ON0056-20090404-njPP1


ADDITIONAL SERVICES WE PROVIDE TO PRACTICES TO GET THEM LIVE
AND TO MEANINGFUL USE

     Contemplation          Implementation Go       Post go live              Meaningful use
                                           live

•                       •                     •                          •




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    Provider outreach       Contract              Revenue cycle              Quality
    & education             accountability        optimization               measures
•   Vendor selection    •   Project           •   EMR consulting         •   Interoperability
•   Group purchasing        management        •   QI consulting          •   Patient
    discounts           •   Workflow          •   PCMH preparation           engagement
•   Readiness               redesign (large   •   Privacy & security •       Biosurveillance
    assessments             practices)            consulting             •   Pay-for-Quality
•                       •                     •




                                                                                                               Printed
    IT consultation         Social                Work flow redesign         program
•   Partners for            networking            (small practices)
    financing &         •   Communication     •   Patient portal
    workforce               outreach              training
    development         •   16 CME credits    •   Interfaces (e.g.,labs,
                            for training          registries)
                                              •   Pilots


                                                                     Primary Care Information Project   | 10
                                                                            DCO-ON0056-20090404-njPP1


CLIENT-FACING TEAMS ARE PHASED IN, AS APPROPRIATE



  eCW project management    ... eCW account management




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 PCIP Outreach

 PCIP implementation management ...   PCIP integration management




                                                                                                        Printed
                         PCIP Billing consulting

                                      PCIP EMR consulting

                                                   PCIP QI consulting

                                                                  PCIP Pay for Quality

                                                                  Panel Management

                                                              Primary Care Information Project   | 11
                                                      DCO-ON0056-20090404-njPP1


AGENDA




                                                                                  Working Draft - Last Modified 4/3/2009 7:03:42 PM
         • PCIP Background

         • The New Federal HIT Agenda




                                                                                  Printed
                                        Primary Care Information Project   | 12
              DCO-ON0056-20090404-njPP1




                                          Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                          Printed
Primary Care Information Project   | 13
                                                                         DCO-ON0056-20090404-njPP1
HIT AND THE FEDERAL STIMULUS BILL
  The American Recovery and Reinvestment Act (ARRA) echoes NYC’s
    investment with $30 billion in health IT incentives contingent on the
    “meaningful use of EHRs” by providers and hospitals.

  The bill provides:




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  1) $2 billion for the Office of the National Coordinator for HIT to
    – Foster health information exchange
    – Develop a national HIT workforce
    – Extend initial loans for adoption
    – Provide EHR implementation assistance through the formation of
      extension centers

  2) Medicaid Incentives for providers (2011)




                                                                                                     Printed
    – For physicians with 30% Medicaid or greater (peds 20%)
    – 85% of Net Allowable Costs, up to $63,750
    – $21,250 upfront (installation, upgrades)
    – $8,500 annual support x 5yrs if “meaningful use” is demonstrated
  3) Medicare incentives for providers (2011)
    – Up to $44,000 for meaningful EHR use over five years
    – Based on percentage of Medicare billings
    – Decrease after 2 years, penalties after year 4
                                                           Primary Care Information Project   | 14
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MEANINGFUL USE GOALS OVER THE NEXT 5 YEARS
  1) Improve quality, safety, efficiency, and reduce health disparities
  ▪ Provide access to comprehensive patient health data for patient’s health care team
  ▪ Use evidence-based order sets and CPOE – e-prescribing
  ▪ Apply clinical decision support at the point of care
  ▪ Generate lists of patients who need care and use them to reach out to patients
  ▪ Report to patient registries for quality improvement, public reporting, etc.




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  2) Engage patients and families
  ▪ Provide patients and families with timely access to data, knowledge, and tools to make
    informed decisions and to manage their health

  3) Improve care coordination
  ▪ Exchange meaningful clinical information among professional health care team




                                                                                                              Printed
  4) Improve population and public health
  ▪ Submit data (immunization, syndromic surveillance and reportable disease) to public
    health agencies

  5) Ensure adequate privacy and security protection for personal health information
  ▪ Ensure privacy and security protections for confidential information through operating
    policies, procedures, and technologies and compliance with applicable law
  ▪ Provide transparency of data sharing to patients

                                                                    Primary Care Information Project   | 15
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TIMELINE OF INCENTIVE PAYMENTS

                       2011      2012      2013      2014     2015     2016         2017          TOTAL

 Medicaid             $21,250   $8,500    $8,500    $8,500    $8,500   $8,500     $0           $63,750

 Medicare             $18,000   $12,000   $8,000    $4,000    $2,000   $0         $0           $44,000




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                                $18,000   $12,000   $8,000    $4,000   $2,000     $0           $44,000

                                          $15,000   $12,000   $8,000   $4,000     $0           $39,000

                                                    $12,000   $8,000   $4,000     $0           $24,000

 No Meaningful Use*                                           -1%      -2%        -3%




                                                                                                                   Printed
      • *Beginning in 2015, providers not satisfying the meaningful use criteria
        will have their Medicare fee schedule amount reduced by 1% in 2015,
        by 2% in 2016, by 3% for 2017 and by between 3-5% in subsequent
        years.

      • Federal funds may not be used for Medicaid incentive payments for the
        purchase of EHR technology after 2016 or for the maintenance of
        EHRs after 2021

                                                                         Primary Care Information Project   | 16
                                                                                        DCO-ON0056-20090404-njPP1


  MEANINGFUL USE REIMBURSEMENT PAYMENTS DON’T COVER THE
  OUTLAYS AT AN INDIVIDUAL PHYSICIAN-LEVEL



                            Physician cost




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                             Medicare incentive
                                                                                                   Net gap:
                                                                                                    -$21K


                                                  -5      +8
$K                                                             -10   +4    -5        +2




                                                                                                                    Printed
                                    -5      +12
        -30

               -5

                      -5      +18


       2009   2010         2011          2012          2013      2014           2015



                                                                          Primary Care Information Project   | 17
Source: MaeHC, 2009
                                                                         DCO-ON0056-20090404-njPP1


MAKE SURE MEANINGFUL USE MATTERS



                                       Checklist
      1. Saving lives                     Item 1
                                                                   $$$




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      2. Improving Quality                Item 2
      3. Lowering Costs
                                          Item 3
                                          Item 4




                                                                                                     Printed
  • We need to keep providers focused on transformative efforts
  • Weed out “piecemeal” vendors
  • Disallow the use of the phrase “meaningful use certified”
  • Hold vendors to high standards
  • Get the payors involved- without reimbursement changes, there will be no
    sustainability
  • Remove the obstacles to eprescribing, lab interfaces and HIE


                                                           Primary Care Information Project   | 18
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SERVICES WE PLAN TO PROVIDE TO PRACTICES TO GET PROVIDERS
LIVE AND TO MEANINGFUL USE

     Contemplation          Implementation Go       Post go live              Meaningful use
                                           live

•                       •                     •                          •




                                                                                                               Working Draft - Last Modified 4/3/2009 7:03:42 PM
    Provider outreach       Contract              Revenue cycle              Quality
    & education             accountability        optimization               measures
•   Vendor selection    •   Project           •   EMR consulting         •   Quality reports
•   Group purchasing        management        •   QI consulting          •   Interoperability
    discounts           •   Workflow          •   PCMH preparation •         Patient
•   Readiness               redesign (large   •   Privacy & security         engagement
    assessments             practices)            consulting             •   Biosurveillance
•                       •                     •   Work flow redesign •




                                                                                                               Printed
    IT consultation         Social                                           Pay-for-Quality
•   Partners for            networking            (small practices)          program
    financing &         •   Communication     •   Patient portal         •   Others TBD
    workforce               outreach              training
    development         •   16 CME credits    •   Interfaces (e.g.,labs,
•   Others TBD              for training          registries)
                        •   Others TBD        •   Pilots
                                              •   Others TBD

                                                                     Primary Care Information Project   | 19
                          DCO-ON0056-20090404-njPP1

PCIP TEAM




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                                                      Printed
            Primary Care Information Project   | 20
                                       DCO-ON0056-20090404-njPP1
EXTRA SLIDES- NOT USED




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                                                                   Printed
                         Primary Care Information Project   | 21
                                                                                                                               DCO-ON0056-20090404-njPP1
                                                                                                                                   •       JULY 16, 2009
Objectives of Ambulatory "Meaningful EHR use" over time (1/3)
                                                                                                                                       •    2015
                                                                                              •    2013
                                •    2011

 •      Improve quality,    ▪ Use CPOE for all orders1                                    ▪   Use evidence-based order         ▪       Achieve minimal
        safety,             ▪ Implement drug-drug, drug-allergy, drug-formulary               sets                                     levels of performance
        efficiency, and         checks                                                    ▪   Manage chronic conditions                on quality, safety, and
                            ▪   Maintain an up-to-date problem list of current and            using patient lists and                  efficiency measures




                                                                                                                                                             Working Draft - Last Modified 4/3/2009 7:03:42 PM
        reduce health
        disparities             active diagnoses based on ICD-9 or SNOMED                     decision support                 ▪       Implement clinical
 ▪   Provide access to      ▪   Generate and transmit permissible prescriptions           ▪   Record family medical                    decision support
     comprehensive              electronically (eRx) (Amb)                                    history                                  for national high
     patient health data    ▪   Maintain active medication and allergy list               ▪   Manage chronic conditions                priority conditions
     for patient’s health   ▪   Record demographics: primary language, insurance              using patient lists              ▪       Medical device
     care team                  type, gender, race, ethnicity                             ▪   Provide clinical decision                interoperability
 ▪   Use evidence-          ▪   Document a progress note per encounter                        support at the point of care     ▪       Multimedia support
     based order sets       ▪   Record advance directives                                                                              (e.g. x-rays)
     and CPOE               ▪   Record vital signs: height, weight, blood pressure,
 ▪   Apply clinical             BMI
     decision support at    ▪   Record smoking status




                                                                                                                                                             Printed
     the point of care      ▪   Incorporate lab-test results into EHR as structured
 ▪   Generate lists of          data
     patients who need      ▪   Generate lists of patients by specific condition and
     care and use them          use for preventive care outreach messages
     to reach out to        ▪   Report selected quality measures to CMS
     patients               ▪   Implement one clinical decision rule relevant to a
 ▪   Report to patient          high clinical priority
     registries for         ▪   Check insurance eligibility electronically from public
     quality                    and private payers, where possible
     improvement,           ▪   Submit claims electronically to public and private
     public reporting,          payers.
     etc.
1 CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but
  electronic interfaces to receiving entities are not required in 2011

SOURCE: HIT Policy Committee; HCI HIT team analysis                                                             Primary Care Information Project      | 22
                                                                                                                                           DCO-ON0056-20090404-njPP1
                                                                                                                                             •    JULY 16, 2009
Objectives of Ambulatory "Meaningful EHR use" over time (2/3)
                                                                                                                              •       2015
                                                                                  •       2013
                                •       2011
 •      Engage              ▪       Provide patients with timely             ▪        Access for all patients to a Person ▪       Patients have access to self-
        patients and                electronic access to/copy of their                Health Record populated in real             management tools
        families                    health information (lab results,                  time with health data               ▪       Electronic reporting on experience
 ▪   Provide patients               problem list, medication lists,          ▪        Offer secure patient- provider              of care




                                                                                                                                                                       Working Draft - Last Modified 4/3/2009 7:03:42 PM
     and families with              allergies) upon request1                          messaging
     timely access to       ▪       Provide access to patient-specific       ▪        Provide access to patient-specific
     data, knowledge,               educational resources                             educational resources in common
     and tools to           ▪       Provide clinical summaries for                    primary languages
     make informed                  patients for each encounter              ▪        Record patient preferences (e.g.,
     decisions and to                                                                 preferred communication media,
     manage their                                                                     advance directive, health care
     health                                                                           proxies, treatment options)
                                                                             ▪        Incorporate data from home
                                                                                      monitoring devices




                                                                                                                                                                       Printed
 •      Improve care        ▪       Capability to electronically exchange ▪           Retrieve and act on electronic      ▪       Access comprehensive patient
        coordination                key clinical information ( problem list,          prescription fill data                      data from all available sources
 ▪   Exchange                       medication list, allergies, test results) ▪       Share an electronic summary
     meaningful                     among providers of care and patient-              care record for every transition
     clinical                       authorized entities                               in care (place of service,
     information            ▪       Perform medication reconciliation at              consults, discharge)
     among                          relevant encounters and each              ▪       Perform medication
     professional                   transition of care3                               reconciliation at each transition
     health care team                                                                 of care from one health care
                                                                                      setting to another


1 Electronic access to and copies of may be provided by a number of secure electronic methods (e.g., PHR, patient portal, CD, USB drive)
2 Transition of care defined as moving from one health care setting or provider to another

SOURCE: HIT Policy Committee; HCI HIT team analysis                                                                       Primary Care Information Project    | 23
                                                                                                                                          DCO-ON0056-20090404-njPP1
                                                                                                                                           •      JULY 16, 2009
Objectives of "Meaningful use" over time (3/3)
                                                                                                                                    •      2015
                                                                                        •      2013
                                         •      2011

 •     Improve population
                                     ▪       Electronically transmit data to        ▪       Receive immunization histories      ▪       Use of epidemiologic data
       and public health
                                             immunization registries where                  and recommendations from            ▪       Automated real-time
                                             required and accepted1                         immunization registries1                    surveillance (adverse
 ▪   Communicate with
                                     ▪       Electronically transmit reportable lab ▪       Receive health alerts from public           events, near misses,




                                                                                                                                                                      Working Draft - Last Modified 4/3/2009 7:03:42 PM
     public health agencies
                                             results to public health agencies              health agencies                             disease outbreaks,
                                     ▪       Electronically transmit syndromic      ▪       Provide sufficiently anonymized             bioterrorism)
                                             surveillance data to public health             electronic syndrome                 ▪       Clinical dashboards
                                             agencies and actual transmission               surveillance data to public         ▪       Dynamic and Ad hoc
                                             according to applicable law and                health agencies with capacity to            quality reports
                                             practice                                       link to personal identifiers

 •      Ensure adequate              ▪       Compliance with HIPAA Privacy and ▪            Use summarized or de-identified     ▪       Provide patients, on
        privacy and security                 Security Rules2                                data when reporting data for                request, with an
        protection for               ▪       Compliance with fair data sharing              population health purposes (e.g.            accounting of treatment,
        personal health                      practices set forth in the Nationwide          public health, quality reporting,           payment, and health care




                                                                                                                                                                      Printed
        information                          Privacy and Security Framework                 and research), where                        operations disclosures
 ▪   Ensure privacy and                                                                     appropriate, so that important      ▪       Protect sensitive health
     security protections for                                                               information is available with               information to minimize
     confidential information                                                               minimal privacy risk                        reluctance of patient to
     through operating                                                                                                                  seek care because of
     policies, procedures, and                                                                                                          privacy concerns
     technologies and
     compliance with
     applicable law
 ▪   Provide transparency of
     data sharing to patient
1 Applicability to Medicare versus Medicaid meaningful use is to be determined
2 The HIT Policy Committee recommends that CMS withhold meaningful use payment for any entity until any confirmed HIPAA privacy or security
  violation has been resolved and that state Medicaid administrators withhold meaningful use payment for any entity until any confirmed state privacy or
  security violation has been resolved

SOURCE: HIT Policy Committee; HCI HIT team analysis                                                                   Primary Care Information Project       | 24
                                                                                                                                     DCO-ON0056-20090404-njPP1
                                                                                                                                       •     JULY 16, 2009
Measures of Ambulatory "Meaningful use" over time (1/3)
                                                                                                                                •     2015
                                                                                        •     2013
                               •      2011

 •      Improve            ▪       Report quality measures to CMS including:            ▪   Additional quality reports using    ▪   Clinical outcome measures
        quality, safety,           – % diabetics with A1c under control                     HIT-enabled NQF-endorsed                (TBD)
        efficiency, and            – % hypertensive patients with BP under control          quality measures                    ▪   Efficiency measures (TBD)
        reduce health              – % of patients with LDL under control               ▪   % of all orders entered by          ▪   Safety measures (TBD)




                                                                                                                                                                 Working Draft - Last Modified 4/3/2009 7:03:42 PM
        disparities                – % of smokers offered smoking cessation                 physicians through CPOE
 ▪   Provide access to                  counseling                                      ▪   Potentially preventable ED visits
     comprehensive                 – % of patients with recorded BMI                        and hospitalization
     patient health                – % of orders (for medications, lab tests,           ▪   Inappropriate use of imaging
     data for patient’s                 procedures, radiology, and referrals) entered   ▪   Other efficiency measures
     health care team                   directly by physicians through CPOE
 ▪   Use evidence-                 – Use of high-risk medications in the elderly
     based order sets              – % of patients over 50 with annual colorectal
     and CPOE                           cancer screenings
 ▪   Apply clinical                – % of females over 50 receiving annual
     decision support                   mammogram
     at the point of               – % of patients at high-risk for cardiac events on




                                                                                                                                                                 Printed
     care                               aspirin prophylaxis
 ▪   Generate lists of             – % of patients who received flu vaccine
     patients who need             – % of lab results incorporated into EHR in coded
     care and use them                  format
     to reach out to               – % of all medications, entered into HER as generic,
     patients                           when generic options exist in the relevant drug
 ▪   Report to patient                  class
     registries for                – % of orders for high-cost imaging services with
     quality                            specific structured indications recorded
     improvement,                  – % claims submitted electronically to all payers
     public reporting,             – % patient encounters with insurance eligibility
     etc.                               confirmed
                           ▪       Stratify reports by gender, insurance type, primary
                                   language, race ethnicity




SOURCE: HIT Policy Committee; HCI HIT team analysis                                                                   Primary Care Information Project   | 25
                                                                                                                                     DCO-ON0056-20090404-njPP1
                                                                                                                                       •     JULY 16, 2009
Measures of "Meaningful use" over time (2/3)
                                                                                                                               •     2015
                                                                                   •     2013
                                   •     2011

 •      Engage patients            ▪   % of all patients with access to personal   ▪   % of all patients with full access to   ▪   NPP quality measures,
        and families                   health information electronically               PHR populated in real time with             related to patient and family
 ▪   Provide patients              ▪   % of all patients with access to patient-       EHR data                                    engagement
     and families with                 specific educational resources              ▪   Additional patient access and




                                                                                                                                                                   Working Draft - Last Modified 4/3/2009 7:03:42 PM
     timely access to              ▪   % of encounters for which clinical              experience reports using NQF-
     data, knowledge,                  summaries were provided                         endorsed HIT-enabled quality
     and tools to make                                                                 measures
     informed decisions                                                            ▪   % of patients with access to secure
     and to manage their                                                               patient messaging
     health                                                                        ▪   % of educational content in
                                                                                       common primary languages
                                                                                   ▪   % of all patients with preferences
                                                                                       recorded
                                                                                   ▪   % of transitions where summary
                                                                                       care record is shared
                                                                                   ▪   Implemented ability to incorporate




                                                                                                                                                                   Printed
                                                                                       data uploaded from home
                                                                                       monitoring devices

 •      Improve care               ▪   Report 30-day readmission rate              ▪   Access to comprehensive patient         ▪   Aggregate clinical
        coordination               ▪   % of encounters where med                       data from all available sources             summaries from multiple
 ▪   Exchange                          reconciliation was performed                ▪   10% reduction in 30-day                     sources available to
     meaningful clinical           ▪   Implemented ability to exchange health          readmission rates for 2013                  authorize users
     information among                 information with external clinical entity       compared to 2012                        ▪   NQF-endorsed Care
     professional health           ▪   % of transitions in care for which          ▪   Improvement in NQF-endorsed                 Coordination Measures
     care team                         summary care record is shared                   measures of care coordination               (TBD)



1 Electronic access to and copies of may be provided by a number of secure electronic methods (e.g., PHR, patient portal, CD, USB drive)
2 Health information exchange capability and demonstrated exchange to be specified by Health Information Exchange Work Group of HIT Policy
  Committee
3 Transition of care defined as moving from one health care setting or provider to another

SOURCE: HIT Policy Committee; HCI HIT team analysis                                                                  Primary Care Information Project     | 26
                                                                                                                                     DCO-ON0056-20090404-njPP1
                                                                                                                                       •     JULY 16, 2009
Measures of "Meaningful use" over time (3/3)
                                                                                                                               •     2015
                                                                                  •     2013
                                     •     2011

 •     Improve population
                                     ▪   Report up-to-date status for childhood   ▪   % of patients for whom an                ▪   HIT-enabled population
                                         immunizations                                assessment of immunization need              measures
       and public health
 ▪   Communicate with
                                     ▪   % reportable lab results submitted           and status has been completed            ▪   HIT-enabled surveillance
                                         electronically                               during the visit                             measure
     public health agencies




                                                                                                                                                                  Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                                                  ▪   % of patients for whom a public
                                                                                      health alert should have triggered
                                                                                      and audit evidence that a trigger
                                                                                      appeared during the encounter




 •      Ensure adequate
                                     ▪   Full compliance with HIPAA Privacy and   ▪   Provide summarized or de-identified      ▪   Provide patients, on
                                         Security Rules                               data when reporting data for health          request, with a timely
        privacy and security
        protection for
                                     ▪   Conduct or update a security risk            purposes (e.g., public health, quality       accounting of disclosure for
                                         assessment and implement security            reporting, and research), where              treatment, payment, and
        personal health




                                                                                                                                                                  Printed
                                         updates as necessary                         appropriate, so that important               health care operations, in
        information
                                                                                      information is available with minimal        compliance with applicable
 ▪   Ensure privacy and
                                                                                      privacy risk                                 law
     security protections for
     confidential information
                                                                                                                               ▪   Incorporate and utilize
                                                                                                                                   technology to segment
     through operating
                                                                                                                                   sensitive data
     policies, procedures,
     and technologies and
     compliance with
     applicable law
 ▪   Provide transparency of
     data sharing to patient

1 Applicability to Medicare versus Medicaid meaningful use is to be determined
2 The HIT Policy Committee recommends that CMS withhold meaningful use payment for any entity until any confirmed HIPAA privacy or security
  violation has been resolved and that state Medicaid administrators withhold meaningful use payment for any entity until any confirmed state privacy or
  security violation has been resolved

SOURCE: HIT Policy Committee; HCI HIT team analysis                                                                 Primary Care Information Project     | 27
                                                                          DCO-ON0056-20090404-njPP1


QUALITY IMPROVEMENT STRATEGY
 • Hire a team with experience in:
      • Nursing
      • Quality improvement
      • Public health
      • Informatics




                                                                                                      Working Draft - Last Modified 4/3/2009 7:03:42 PM
      • Pharmaceutical detailing
      • Care management
 • Replicate the pharma sales model by assigning practices to QI specialists by
  “territory”

     • 10 site visits (once every 5-6 weeks) per practice




                                                                                                      Printed
 • Disease-focused format sessions- minimum of 30 minutes to 1 hour with the
  physicians and other office staff

 • For now, focused on Internal Medicine & Family Medicine physicians, just
  started pediatricians (not working with ObGyns, and specialists)

 • Each QI specialist manages 25-30 practices
                                                            Primary Care Information Project   | 28
                                                                   DCO-ON0056-20090404-njPP1
WHAT IS THE GOVERNMENT’S ROLE?

• To ensure that electronic health record systems address public
  health priorities

• To use economies of scale to support implementation efforts




                                                                                               Working Draft - Last Modified 4/3/2009 7:03:42 PM
• To support quality improvement by promoting and harmonizing
  quality-linked funding streams

• To help provider groups optimize their EHR configuration and use




                                                                                               Printed
                                                     Primary Care Information Project   | 29
                                                                                   DCO-ON0056-20090404-njPP1

Current State & Limitations of Biosurveillance in NYC

                                       Limitations
Current State                           Data Issues

•1) Public health officials receive     ▪ Information and recommendations constantly




                                                                                                               Working Draft - Last Modified 4/3/2009 7:03:42 PM
data from numerous sources:                 changing
▪ Notifiable disease reports (URF)      ▪   DOH can only provide, not receive data
▪ Syndromic surveillance (ER,               directly from practices other than existing
  PCIP practices)                           hardcoded queries
•2) Data are monitored & analyzed
                                        ▪   Practice contact information changes
for abnormalities and potential         ▪   Difficult to track novel outbreaks in real time
threats.                                    and provide information to providers in the
                                            field in real time at POC




                                                                                                               Printed
•3) Alerts are then shared to notify
healthcare providers and the            Contextual and Workflow Relevance
public
▪ Fax and email to provider offices     ▪ Notified on Monday, forgotten by Friday
  across NYC usually some time
  after the fact
                                        ▪ Alerts not contextually relevant, not tailored
                                            to patients being seen
                                        ▪   Paper alerts are not actionable, not
                                            integrated into workflow



                                                                     Primary Care Information Project   | 30
                                                                                              DCO-ON0056-20090404-njPP1
CURRENT PROCESS FOR NOTIFIABLE DISEASE REPORTING AND GIVING FEEDBACK
TO PROVIDERS



                                             SOAP Note                URF




                                                                                                                          Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                Fill out

       Patient      Provider (handwritten)                                                Mailed




 • MMWR




                                                                                                                          Printed
 • Mass media
 • Peer-reviewed
   literature
                                                         Analyst



                             HAN alert


        Problem: Information not integrated into clinical workflow, and not at the point of care


                                                                                Primary Care Information Project   | 31
                                                                                   DCO-ON0056-20090404-njPP1

Current State & Limitations of PCIP Quality and Utilization Reporting in NYC


                                               Data Issues
▪   Quality Measurement                        ▪ Information & recommendations
    – ABCS                                       constantly changing
    – Contextually relevant decision support   ▪ DOH can neither provide nor receive
      at point-of-care                           data directly from practices other than
    – Provider/Practice Benchmarking with




                                                                                                               Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                 existing hardcoded queries
      feedback and quarterly report cards      ▪ Cannot adapt to new initiatives with
    – Targeted QI efforts                        new reporting requirements (local,
    – Trending over time                         federal)
    – P4Q – Reimbursement reform
                                               Contextual and Workflow Relevance
▪   EHR Utilization                            ▪ Although innovative, quality
    – E-prescribing                              measurement and CDSS remains
    – CDSS and CPOE                              inflexible and hard coded
    – Referral tracking                        ▪ Cannot integrate new local quality




                                                                                                               Printed
    – Practice Management Data/RVU               initiatives at the point of care, within
      Analysis                                   clinical workflow
    – Vaccines Reported to CIR                 ▪ Cannot adapt to changing quality
    – Patient Portal                             measures and best practice
                                                 recommendations




                                                                     Primary Care Information Project   | 32
                                                                                DCO-ON0056-20090404-njPP1

Solution for Biosurveillance/Quality

   •Distributed query architecture and alerting system
   •Agile and flexible distributed community enterprise
   ▪ Using current registry functionality at the enterprise/community level with
     new modifications
     – Can adapt to new quality measures




                                                                                                            Working Draft - Last Modified 4/3/2009 7:03:42 PM
     – Can adapt to emerging outbreaks
   ▪ Reporting only, or reporting + CDSS with distributed ordersets
   ▪ Actionable, contextually relevant point-of-care alerts pushed to provider
     right pane
   ▪ Information also can be pushed to provider message inbox

         This new flexibility allows




                                                                                                            Printed
         ▪ Rapid adaptation to emerging threats
         ▪ Integration of information into the clinical workflow
         ▪ Delivery of information in a specific and contextually
           relevant manner
         ▪ Collection of additional patient history, ordering of essential
           diagnostic tests, and delivery of appropriate treatment via
           actionable order sets
         ▪ Ad hoc reporting summarized data back to DOHMH
                                                                  Primary Care Information Project   | 33
                                           DCO-ON0056-20090404-njPP1




                                                                       Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                                       Printed
Cough & Fever
                  Provider
        Patient              Primary Care Information Project   | 34
                                                                    DCO-ON0056-20090404-njPP1


GOALS OF OUR HQIN ACTIVITIES

  DOHMH         • Provide real-time data to DOHMH to asses health of
                  New Yorkers (chronic conditions & preventable
                  diseases)
                • Identify gaps in care where policies, programs or




                                                                                                Working Draft - Last Modified 4/3/2009 7:03:42 PM
                  interventions can improve (or are improving) health
                  promotion and prevention

                • Actionable information to providers that
  Provider
                  reinforces public health goals by providing timely
                  and usable performance feedback
                • Complements onsite QI efforts, allowing for




                                                                                                Printed
                  tracking of improvements and benchmarking


  Others        • Create or co-develop novel provider
                  reimbursement/pay-for-quality programs
                  that extend public health goals



                                                      Primary Care Information Project   | 35
                                                                              DCO-ON0056-20090404-njPP1


Generate actionable information for improving the delivery of
preventive services
•

• DATA SOURCES                              • CURRENT USES




                                                                                                          Working Draft - Last Modified 4/3/2009 7:03:42 PM
• Clinical Quality*                         • Identify gaps in care
• Providers                                 • Feedback to programs
  Characteristics**                         • Assess impact on
• Secondary data***                           health and costs




                                                                                                          Printed
 •   *Based on USPSTF recommended guidelines, traditionally assessed through
     administrative data sources or manual patient record review
 •   **Surveys, organizational structure, use of information systems
 •   *** Billing, number of encounters, service codes



                                                                Primary Care Information Project   | 36
                                                                                      DCO-ON0056-20090404-njPP1


HEALTHCARE QUALITY INFORMATION NETWORK (HQIN)
                                                                DOHMH
                                                          HQIN Data Warehouse

                                                            Data Quality Control
                                                  • Verification of Transmissions




                                                                                                                  Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                        •Who is transmitting
                                                        •Content of information
                                                        •Missing items
                                                  • Maintenance
                                                        •Incorporating new sources (e.g. new
                                                        practices)
                                                        •Updating revised sources (e.g. new
                                                        measures)




                                                                                                                  Printed
                                                          Access and Reporting
                                                  • PCIP staff
                                                       •Analytics
                                                       •Dissemination to practices
                                                       •Program Evaluation
                                                       •Contract based reporting to 3rd parties
                                                  • Non-PCIP
   PCIP practice in process of adopting EHR
                                                       •DOHMH programs
   PCIP practice using subsidized EHR
                                                       •Research Collaborations and Consultants
   Practice transmitting aggregate data to HQIN

                                                                        Primary Care Information Project   | 37
                                                                                             DCO-ON0056-20090404-njPP1

ANATOMY OF QUALITY DATA IN HQIN
     • From Each Provider Transmitting to HQIN:
       •         No. of Patients receiving or
            meeting a recommended
            treatment goal                                    •        % of Patients
                                                              ═




                                                                                                                         Working Draft - Last Modified 4/3/2009 7:03:42 PM
       •         No. of Eligible patients for a                    meeting a quality goal
            recommended service or
            treatment goal

                                                 Numerato                      % meeting
 • Examp                            Measure*            r      Denominator          goal          Population
                                                                                                  asked by a




                                                                                                                         Printed
         le: Provider 1
  Practice 1                   Smoking Status            10               20            50.0      providers if they
                                                                                                  are a smoker
  Practice 2   Provider 1      Smoking Status             5                8            62.5
  Practice 2   Provider 2      Smoking Status            20               35            57.1
  Practice 3   Provider 3      Smoking Status             3                3           100.0
                                          sum            38               66            57.6
                                                                                                    Population
                              Provider average          9.5             16.5            67.4        needing advice,
                              Practice average          8.5             16.2            69.4        counseling or Rx
                                                                                                    for cessation
*Currently, there are 37 quality measures being reported based on TCNY indicators
                                                                               Primary Care Information Project   | 38
                                                                                  DCO-ON0056-20090404-njPP1


  PCIP GETS UP-TO-DATE DATA FROM A VARIETY OF SETTINGS

   Collection
            N => 200            N => 100           N => 10                N=1

            Clinics             CHCs             Hospitals                RHIO




                                                                                                              Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                           HHC Outpatient:
                                           Real time
 eCW reporting:                            ambulatory care
 Develop new case definitions              data




                                                                                                              Printed
 Reportable diseases:
 Electronic forms                                            CDC Contract:
                                                             • Map data elements
Nick and win       RDP Project:                              • Establish PHINMS
to simplify this   • Develop decision supports                 connectivity
slide and make     • Prompt for lab orders                   • Establish data sharing
the boxes          • Link encounters to
more relevant        questionnaires

                                                                    Primary Care Information Project   | 39
                                                                           DCO-ON0056-20090404-njPP1

  WE CONDUCT A VARIETY OF ANALYSES IN ADDITION TO HELPING
  OTHER GROUPS AT DOHMH ACCESS DATA
H1N1: Detect events
using time-series methods

                   Seasonal influenza: Build statistical




                                                                                                       Working Draft - Last Modified 4/3/2009 7:03:42 PM
                   models to estimate baseline

  Analysis




                                                                                                       Printed
  Evaluation studies: Assure data quality and validity
                                                           CIR reporting: Monitor
                                                           processes using quality
  SAS eBI Data Warehouse: Maintain and
                                                           control methods
  administer analytical tools for researchers
  - Epiquery, BCD, A1C registry
                                                             Primary Care Information Project   | 40
                                                           DCO-ON0056-20090404-njPP1


PCIP RECEIVES VARIOUS FEEDS OF DATA- AN ILI EXAMPLE




                                                                                       Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                                                       Printed
                                             Primary Care Information Project   | 41
                                                          DCO-ON0056-20090404-njPP1


SEPTEMBER SEASONAL INFLUENZA LEVELS ALREADY ABOVE
EPIDEMIC LEVELS




                                                                                      Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                                                      Printed
* Based on model built by Marlena for BCD




                                            Primary Care Information Project   | 42
                                                                                          DCO-ON0056-20090404-njPP1
  FOR THE SPRING H1N1 OUTBREAK, WE COULD SEE THE PATIENTS
  WERE VISITING THE EDS INSTEAD OF PCPS

       Cumulative % Of Facilities With A Significant Increase In ILI And % Of Daily Visits For ILI




                                                                                                                      Working Draft - Last Modified 4/3/2009 7:03:42 PM
  ED




                                                                                                                      Printed
PCIP
practices




                                                                            Primary Care Information Project   | 43
                                                                                          DCO-ON0056-20090404-njPP1
  FOR THE FALL H1N1 OUTBREAK, WE ARE SEEING TBD


       Cumulative % Of Facilities With A Significant Increase In ILI And % Of Daily Visits For ILI




                                                                                                                      Working Draft - Last Modified 4/3/2009 7:03:42 PM
  ED                  TBD                                               TBD




                                                                                                                      Printed
PCIP                  TBD                                               TBD
practices




                                                                            Primary Care Information Project   | 44
                                                                    DCO-ON0056-20090404-njPP1
IMMUNIZATION REPORTING IMPROVES SIGNIFICANTLY WITH EHR
ADOPTION             Pre-EHR Post-EHR




                                                                                                Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                                                                Printed
                         Go-live date
                         (2/27/08)




Data example from high-volume Brooklyn pediatrician   Primary Care Information Project   | 45
                                                                        DCO-ON0056-20090404-njPP1


Data and Analysis

 Providers          • Create epidemiologic awareness:
                       – Community influenza trends




                                                                                                    Working Draft - Last Modified 4/3/2009 7:03:42 PM
 DOHMH              • Contribute detailed clinical data
                       – Measured temperature, Lab
                         results




                                                                                                    Printed
 PCIP               Inform PCIP teams: QI,
                    Development, Implementation,
                    HQIN



                                                          Primary Care Information Project   | 46
                                                                              DCO-ON0056-20090404-njPP1


Who will be eligible for meaningful use (Physicians)

  Medicaid
  ▪ Must meet minimum Medicaid patient volume percentages
       ▫ 30% minimum for Adult practices
       ▫ 20% minimum for Pediatrics practices
  ▪ Payments are not based on Medicaid billings




                                                                                                          Working Draft - Last Modified 4/3/2009 7:03:42 PM
  ▪ Eligible professionals include physicians, dentists, certified nurse-midwives,
    nurse practitioners, and physician assistants who are practicing in Federally
    Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) led by a
    physician assistant.
  ▪ Cannot receive duplicative Medicaid and Medicare EHR incentives




                                                                                                          Printed
  Medicare
  ▪ Incentives may be up to 75% of total Medicare billing, below a yearly cap
    (phased down from $18,000 in 2011)
  ▪ Hospital-based physicians who substantially furnish their services in a hospital
    setting are not eligible.
  ▪ Payments increased by 10% for physicians practicing in a Health Professional
    Shortage Area


                                                                Primary Care Information Project   | 47
                                                                                       DCO-ON0056-20090404-njPP1


Overview of Payment Incentives

   •     Medicaid
   ▪   May receive up to 85% of the net average allowable costs for certified EHR technology,
       including support and training

   ▪ Incentive payments are available for no more than a 6-year period




                                                                                                                   Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                 or
   Medicare
   ▪ May receive incentives of up to 75% of Medicare allowable charges for covered services
     furnished by the provider up to a yearly cap. The total potential reward is $44k over five
     years

   ▪   For early adopters whose first payment year is 2011 or 2012, the maximum payment is
       $18,000 in the first year.




                                                                                                                   Printed
   ▪   No payments to providers who first become meaningful EHR users in 2015 or thereafter.

   ▪   Health professional shortage area (HPSA) qualifying providers will have their incentive
       payments increased by 10 percent.

   ▪   Starting in 2015, physicians who have not achieved Meaningful Use will face a 1%
       Medicare payment penalty, growing to 3% by 2017


SOURCE: The Centers for Medicare and Medicaid Services Website           Primary Care Information Project   | 48
                                                                     DCO-ON0056-20090404-njPP1


Key Questions That Remain

 1. How will providers demonstrate to CMS that they meet Meaningful
    Use criteria
 2. How will Meaningful Use be scored across the final measures?
    Are all “Must Pass”?




                                                                                                 Working Draft - Last Modified 4/3/2009 7:03:42 PM
 3. How will CMS determine Medicare eligibility? Based on Medicare
    billing for the year prior to Meaningful Use demonstration (2010?)
    Or 2011? Will they reassess every year? What if your percent
    medicare dips in one year, or goes up? Does your payout
    change?
 4. How will Medicare Advantage plans factor in to eligibility?




                                                                                                 Printed
 5. Is there a minimum Medicaid patient count to quality? Where do
    low FTE physicians fit? Or physicians whose work is divided
    between practices?
 6. More Questions?




                                                       Primary Care Information Project   | 49
                                                                                                       DCO-ON0056-20090404-njPP1

                        NYC Extension Center Governance
                    Primary Care Information Project                                        FPHNY

          PCIP DOHMH                                 Extension Center Core Management
 • Biosurveillance                   •   Regional Center Accountability         • Fiscal management
 • Public health development         •   Adoption support                       • Grants & contracts administration
 • Quality reporting                 •   Meaningful Use training                • Membership services website




                                                                                                                                   Working Draft - Last Modified 4/3/2009 7:03:42 PM
 • Evaluation                        •   Workforce development                  • Provider invoicing
 • Health Information                •   National Learning Consortium           • Private fundraising
   Exchange                                                                     • ARRA reporting




                                                         Stakeholder Community*
                   Clinical Advisory Board*
                                                         • DOHMH
                   • Small Practice physicians
                                                         • NYS Extension Center




                                                                                                                                   Printed
                   • CHC physicians
                                                         • Institute for Family Health
                   • HHC physicians
                                                         • CHCANYS
                   • Others TBD
                                                         • PCDC
                                                         • PCHIC
                                                         • GNYHA
                                                         • NYS DOH
                                                         • NYEC
                                                         • Others TBD




*Clinical Advisory Board & Stakeholder Community will be formalized if and when we are
                                                                                         Primary Care Information Project   | 50
  selected to be an extension center
                                                                                   DCO-ON0056-20090404-njPP1



                                  What To Expect: PCIP
                                  Timeline
       Weeks 1 - 4              Weeks 5-16                          Ongoing…




                                                                                                               Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                                      Start
    Getting Started           Installing EHR          Using       After Installation
                                                      EHR

•   EHR Education       •   Project Kickoff                   •   Practice Redesign
•   PCIP Application    •   Customized Project plan           •   Privacy & Security
•   IT consultation     •   Hardware purchasing &             •   Meaningful Use
•   Budget, Financing       installation                      •   Pay For Performance
    options             •   Network setup                     •   Biosurveillance
•   Agreements          •   EHR installation                  •   Other DOHMH Resources
                        •




                                                                                                               Printed
                            Billing
                        •   Migration of patient
                            information
                        •   Training
                        •   Software support




                                                                     Primary Care Information Project   | 51
                                                                                                                               DCO-ON0056-20090404-njPP1




Most Providers Lack Quality Improvement Tools



                            Multivariate Analyses: Effects Of Practice Size On Access To
                            Practice-Level And Quality-Of-Care Data, Physicians’ Ability
                            To Generate Quality-Of-Care Data Internally, And Physicians’




                                                                                                                                                           Working Draft - Last Modified 4/3/2009 7:03:42 PM
                                        Involvement In Redesign Efforts, 2003


                 Involved in redesign
                   efforts (n=1,744)


                  Quality-of-care data                                                                               Solo (1)e
                 internally generated                                                                                Small (2-9)
                       (n=1,705)




                                                                                                                                                           Printed
                                                                                                                     Midsize (10-49)
                                                                                                                     Large (50 or more)
               Access to any quality-
               of-care data (n=1,757)


                      Access to any
                    practice-level data
                        (n=1,757)

                                              0        10       20       30        40       50       60         70        80      90      100

                                                                              Proportion of Physicians, %   *
* Model controls for practice size, years in practice, hours a week in direct patient care, salary status, physician type (primary care vs.
specialist), certification status in specialty, and use of EMR.
  Audet AMJ, Doty MM, Shamasdin J, Schoenbaum SC. Measure, Learn, And Improve: Physicians’ Involvement In Quality Improvement. Health
                                                                                                 Primary Care Information Project | 52
  Affairs. 2005; 24: 843-853.

				
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