The Primary Care Information Project

Slide presentation from the AHRQ 2009 conference.

On September 15, 2009, Sarah Shih, MPH made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (2 MB) (Plugin Software Help).

Slide 1

The Primary Care Information Project

Sarah Shih, MPH
Exec. Dir. Healthcare Quality Information
New York City
Department of Health and Mental Hygiene


Slide 2

NYC's Health Agenda
Take Care New York

  1. Have a Regular Doctor or Other Health Care Provider
  2. Be Tobacco-Free
  3. Keep Your Heart Healthy
  4. Know Your HIV Status
  5. Get Help for Depression
  6. Live Free of Dependence on Alcohol and Drugs
  7. Get Checked for Cancer
  8. Get the Immunizations You Need
  9. Make Your Home Safe and Healthy
  10. Have a Healthy Baby


Slide 3

Health Care that Maximizes Health

  • Health Information Systems that are oriented toward prevention
  • Redesigned Practice Workflows Patient Engagement that highlights prevention
  • Payment that rewards disease prevention and the effective management of chronic disease


Slide 4

Focused on Medically Underserved Patients in NYC

We have secured signed commitments from 2,100 providers in 379 practices and at 480 sites

~ 1 new provider goes live on the EHR every day

PracticesLiveIn ProgressPractice IS ratio
Small Practices2479686:1
Health Centers1813*15:1
Hospital OPDs32*4:1

*Practice with sites both live and in implementation


Slide 5


Kaiser Permanente > NYC PCIP


Slide 6

PCIP, eCW & Practice team structure

Implementation specialistsProject Managers, Business Analysts, SAMSProviders, Office ManagersProject Management Team
Infrastructure teamTechnical SpecialistsIT ConsultantIT Department
Interface Coordinator (PM, labs and CIR)Lab Interface teamProviders, Office ManagersIT Department, Ref/In-house lab
Quality AssuranceDevelopement teamProviders, Office ManagersSite Administrators
Quality Improvement consultants, Supers Users, Billing consultantsTrainers, Billing Specialists, Business AnalystsProviders, Office Managers, BillerQuality Improvement Unit, Financial Dept.
Privacy and Security consultantsDevelopment teamProviders, Office managersIT Department, Legal
Development teamDevelopment teamProviders, Office ManagersSuper Users



Slide 7

8 Key Features of the TCNY Build

  1. Measure Reports
    Side-byb-side provider comparisons of performance on quality measures
  2. Enhanced Registry
    Identifies patients by structured data (e.g., diagnoses, drugs, labs, demographics)
  3. Automatic Visual Alerts
    Highlights abnormal vitals
  4. CDSS
    Automatically displays preventive service alerts that are suppressed when addressed
  5. Quick Orders
    One-click ordering of recommended preventive services
  6. Comprehensive Order Sets
    Displays best practice recommendations (e.g., for meds, labs, patient education)
  7. eMedNY
    With patient consent, displays 90-day history of all Rxs filled by Medicaid patients
  8. CIR School and Health
    Sends information to City Immunization Registry and generates school health forms


Slide 8

Small Practice Consulting Approach

Client-Facing Teams are phased in, as appropriate


Slide 9

Following Medical Home and Chronic Care Models

Useful framework for organizing QI work

  • Actionable curriculum consisting of a collection of discrete activities and achievable goals
  • Focus on "whole-practice" redesign (e.g. teamlet care - C. Sinsky)
  • Provide actionable and meaningful feedback
  • View EHR-derived quality measure data on a routine basis
  • Provides incremental recognition


  • Assist practices through the process and lower the "activation energy"
    • Software, QI, EMR consulting, Pay for Performance, relationships
    • Partnership with NCQA- multi-site survey
  • Keep practices focused on care & and reduce administrative burdens
    • Average physician spends $68,274 per year interacting with insurance plans*
  • Focus practices on areas to have the highest impact for health
  • Provide share resources to practices (care coordinators, nurses, panel managers)
  • Conduct patient outreach using the data from EHR

*J. A. Sakowski, J. G. Kahn, R. G. Kronick et al., "Peering into the Black Box: Billing and Insurance Activities in a Medical Group," Health Affairs Web Exclusive, May 14, 2009, w544-w554

Slide 10

How do we know whether providers are meaningfully using the EHR?

  • PCIP staff
    • Scheduled on-site visits
    • Demo of registry query functions
  • Data Transmissions from EHR
    • Encounter information from PM
    • Utilization of EHR metrics
    • Quality Measures (EoC)


Slide 11

Average Encounters Per Month by Practice Size*

Bar graph depicting average encounters per month up to three providers.

*Limited to small practices that have been on the EHR for 6 months or more.
Data available on ~116 small practices


Slide 12

PCIP Contractual Expectations with Providers
Selected Measures for Demonstrating Use of EHR

  1. Visits where office visit CPT codes were entered into the progress note.
  2. Visits where an order set was used as part of the progress note.
  3. Visits where a smart form was used as part of the progress note.
  4. Visits where blood pressure was entered into the progress note.
  5. Visits where allergy data was entered in a structured format
  6. Insurance claims created over total number of insurances for patients that month
  7. Visits where medications were prescribed through the EHR
  8. Prescriptions entered into the EHR that were sent via fax or electronic interface
  9. Labs reviewed over labs ordered
  10. Current medications were entered or verified in the EHR
  11. Months in a 6 month period when required data files were transmitted to the DOHMH
  12. Months in a 6 month period when all core utilization measures were reported to the DOHMH


Slide 13

Proposed Meaningful Use Measures Overlapping with Data Transmitted to PCIP

Line2011 Measures (Draft from HITECH)Level
9,10% of permissible RX's transmitted electronicallyProvider
21,22% lab results incorporated into EHR in coded format [OP,IP]Practice Provider
26% of encounters for which clinical summaries were provided [OP, IP]Provider
28% of encounters where med reconciliation was performed [OP, IP]Practice
30Report up-to-date status for childhood immunizations [OP]Practice
31% reportable lab results submitted electronically [IP]Practice


Slide 14

EHR Utilization Transmitted to PCIP

  • Snapshot of monthly activities
  • Number of practices with EHR use data
    • 133 practices in July and August 2009
    • 85 have been using EHR for 8 months or longer
EHR use transmissionsTotal Jul*Total Aug*
Lab results transmitted48,07252,183
Lab results reviewed56,73163,882
Use of Medicaid State Rx Claims2,4222,560
Active patients508,079516,283

*limited to practices on the EHR for 8 months or longer


Slide 15

Proposed Meaningful Use Measures Currently within PCIP Quality Measures

Line142011 Measures (Draft from HITECH)
1% diabetics with A1c under control [OP]
2% of hypertensive patients with BP under control [OP]
3% of patients with LDL under control [OP]
4% of smokers offered smoking cessation counseling [OP, IP]
5.6% of patients with recorded BMI [OP]
14% of patients over 50 with annual colorectal cancer screenings [OP]
15% of females over 50 receiving annual mammogram [OP]
16% of patients at high-risk for cardiac events on aspirin prophylaxis [OP]
17% of patients with current pneumovax [OP]
19% eligible patients who received flu vaccine [OP]

Note: Quality Measures are collected at the provider level and stratified by insurance type. For some practices, stratified by race/ethnicity, though few providers are completing the field for race/ethnicity


Slide 16

Preliminary Data - Quality Measures

 Mar08 to Feb09Aug08 to Jul09
Measure NameNMean (std)Sum*NMean (std)Sum*
A1C control (< 7%)1253.7 (16.6)4924447.2 (17.0)2,498
Antithrombic Treatment5847.5 (21.2)8,6178949.6 (21.3)13,686
Asthma control (5-11 yrs)387.8 (18.4)49489.0 (12.4)104
Asthma control (12-17 yrs)274.1 (16.4)22390.6 (8.4)54
Asthma control (18-56 yrs)245.7 (36.4)121161.9 (27.5)105
Body Mass Index8661.6 (29.8)83,02911070.4 (26.9)126,842
BP Control ≤130/80 DM5623.9 (13.5)4,9227830.7 (17.3)7,358
BP control ≤140/90 HTN6348.6 (16.4)12,3058551.9 (16.0)18,480
BP Control ≤140/90 IVD3267.4 (16.3)6504669.7 (20.1)868
Cholesterol Control <100 gen pop1463.4 (22.5)5734852.2 (21.3)3,145
Cholesterol Control <100 IVD,DM1565.3 (18.5)8743762.4 (15.7)1,879
Breast cancer screening164.5 (5.8)6,346515.2 (7.9)22,034
Colorectal cancer screening81.9 (1.3)4,126463.9 (6.2)22,008
Influenza vaccine (over 50)4822.6 (18.4)25,5507015.6 (15.2)38,431
Pneumococcal vaccine669.8 (13.0)27,352989.8 (13.5)45,641
Smoking cessation intervention4519.0 (14.5)4,7987929.7 (23.6)8,253

*A population estimate was derived by summing across practice denominators per measure


Slide 17




Current as of December 2009
Internet Citation: The Primary Care Information Project. December 2009. Agency for Healthcare Research and Quality, Rockville, MD.