Electronic Medical Records Electronic Medical Records Can Help Eliminate Racial Disparities in Health Outcomes

Neil Calman, MDPresident and CEOKwame Kitson, MDMedical DirectorThe Institute for Urban Family Health

September 2004

What do we mean by health disparities?

Defining Health DisparitiesA difference in life expectancy between people of color and whites - whites have a life expectancy of approximately 7 years longer than African-AmericansA difference in health care access and in the treatment given by health care providersA difference in the outcomes of diseases all else being equalA difference in the complication and death rates of common diseases

Documenting Racial Disparities ..LIFE EXPECTANCY

Diabetes ComplicationsKidney DiseaseThe rate of diabetic end stage renal disease is 2.7 times higher among African Americans than among whites.Eye DiseaseRates of blindness due to diabetes are only half as high for whites as they are for rest of the population.MortalityDiabetes-related mortality rates for African-Americans, Hispanic Americans, and American Indians are higher than those for white people.Source: CDC/ AHRQ

Cancer

Hispanics have a higher incidence and higher mortality rates due to cancer of the stomach, liver, and cervix than non-Hispanic Whites. (Source: American Cancer Society)

Disparities in Diagnostic CareThe length of time between an abnormal screening mammogram and the follow-up diagnostic test to determine whether a woman has breast cancer is more than twice as long for Asian American, black, and Hispanic women as for white women. (Source: CDC/ Agency for Healthcare Research and Quality)

Discrimination in CareSource: Kaiser Family Foundation

CDC Grant to End Disparities in Diabetes and Cardiovascular Disease in the Bronx Covers 4 Zip codes in the Bronx with a total population of 250,000 peopleCoalition of 40 community-based organizations and faith organizationsMany patients have enormous health and social problems that need to be addressesPrimary and secondary prevention often take a back seat to dealing with urgent issuesThe check-up is replaced by dealing with health maintenance issues at every visit

The Institute for Urban Family HealthOwns 6 Federally-qualified community health centers (FQHCs) and operates 6 other centers for Continuum Health Systems its partner hospital system.Operates 9 additional part-time sites which provide care to people who are homelessCo-sponsors a family medicine residency program and operates its model family practiceReceives 18 different Federal, State and private grants to serve people with special health care needs

EPICInstalled in 12 full-time centers in Fall 2001 with EpicCare roll-out in Spring 2002

Installed in Residency Program July 2004

Installation planned for part-time homeless health care sites for 2005

Focus Group Findings On Trust:

For a black man and a white man with the same symptoms, they send the Black man home and put the white guy in the hospital for observation. The Community Speaks .

How We Build Trust Roles and responsibilities of health care providers in the information age Provide information to patients to help them make decisions about their own health-related behaviors and their own health care choices Provide advice, diagnosis and treatment of health care problems as well as preventive health guidance and procedures Provide care in a way that safeguards patients from medical and nursing errorsMaintain a complete database of readily available health education informationMake health education materials readily available to themLet them own their own medical records

The Institutes Implementation of EMRs to Reduce Health Disparities:Flat Panel DisplaysFlat Panel displays were chosen so they could be seen by both the provider and the patient.This changes the fundamental sense of secrecy that has previously surrounded the medical recordTablets were rejected because they were the least able to be shared with patientsWorkflows and dialogs have to be re-learned to be comfortable using the display as part of the patient encounter.

The Institutes Implementation of EMRs to Reduce Health Disparities:Printers in Every Exam RoomEpic provides excellent resources for making patient education a part of the encounterWe routinely print a custom designed After Visit Summary which has patient friendly headers like These are the vital signs that were taken today and There are the orders that were made today in your carePatients are encouraged to review and keep copies of all of their AVS notesLabs which come back through the interface can be printed and a copy given to patients in the exam room

The Institutes Implementation of EMRs to Reduce Health Disparities:Printers in Every Exam RoomHealth education materials available in both English and Spanish are printed in the exam room and may be annotated as the provider reviews the information for the patientWeight and Blood Pressure Monitoring can be graphed and printed for the patients an excellent motivational tool especially if they are doing wellPatients walk out with paper sufficient to provide them a complete view of their health status and details of all the things that were recorded about them.

The Institutes Implementation of EMRs to Reduce Health Disparities:ReportsWe are now able to follow-up on issues never before possible. Consults ordered but no report has been receivedChronic medications that are not being renewed at the right intervalsPatients who are missing certain health maintenance procedures appropriate for their gender and age

The Institutes Implementation of EMRs to Reduce Health Disparities:BPAsIn low income communities of color in New York City, patient have many social and economic concerns and health care is sometimes relegated to a lower priorityWe have eliminated the concept of the check-up and used BPAs to remind providers at every visit of what health maintenance and early detection procedures are needed at the time of every visitReports enable us to outreach to patients who are not coming in for a visit but who are missing critical health maintenance procedures

The Institutes Implementation of EMRs to Reduce Health Disparities:LettersProviders are encouraged to send letters to patients with all results that come back from diagnostic proceduresMany templated letters make communication with patients easier and provide patients with further documentation of what tests they had done and what the next step is.Receiving communications from doctors helps to build a trusting relationship.If patients expect results letters than they stop calling the office for results and this increases efficiency of the practice

Questions for Thought !Ethical questions we must still face in the roll-out of electronic medical records How do we redefine the roles and responsibilities of the providers and the patients ?What do we do with all the information we now have ?What responsibility do we have to reach out to patients with information ?Where do the resources come from in the outreach and follow-up which needs to be done ?How do we prioritize our efforts without an adequate scientific basis for what we are doing ?

X

Using Technology to Improve Quality of CareKwame A. Kitson, MDMedical DirectorThe Institute for Urban Family Health

IUFH Pre-EpicCare CQI ReviewResource allocation limited organization- wide QI topic review to three topics per year.Areas covered included HIV, diabetes, adolescent screening for tobacco and substance abuse, postpartum careInterventions that worked best were those that facilitated better documentation by providers (example: stamps)

IUFH Pre-EpicCare CQI ReviewAverage time spent on chart review- 30 minutes to one hour per chart depending on the studyAverage time it took to complete studies- 3 months.Chart reviewers were doctors and nurses at our centers. Time spent on chart review made it more difficult for them to complete other administrative tasks and patient follow-ups

The Transition OF CQI into EpicCareIUFH transitioned all 13 centers into EpicCare between October 2002 and January 2003Within the first six months provider productivity matched pre-EpicCare levels.In 2004, unprecedented productivity levels have been seen.

October 2003- Release of Superhero Best Practice Alerts

BEST PRACTICE ALERTS

PNEUMOVAX SEASONAL FLUVAXBREAST CANCER SCREENINGCERVICAL CANCER SCREENINGLEAD SCREENINGMAMMOGRAPHY SCREENING

BEST PRACTICE ALERTSOPHTHALMOLOGY CONSULTS FOR DIABETICSHGBA1C TESTING AND CONTROLPEAK FLOW MEASUREMENTS FOR ALL ASTHMATICSNEPHROLOGY CONSULTS FOR PATIENTS WITH GREATER THAN 1.8 SERUM CREATININELDL SCREENING LIVER FUNCTION TESTING FOR PATIENTS ON STATINS and many others.

DID IT WORK ?Initial concern about the introduction of best practice alerts (BPAs) replaced by enthusiasm for the improvement seen in multiple clinical areas.

Keys to Success: Making sure the BPAs used generally accepted standards for testing and treatment indicationsMaking sure that the BPAs were accurate in capturing services rendered (e.g. there are many CPT codes PAP testing)

An Exponential Increase in CQI Activity EPICCARE/CLARITY DATABASE WITH CRYSTAL REPORTING HAVE ALLOWED FOR AN EXPNENTIAL INCREASE IN REPORTING.

OVER A DOZEN CLINICAL AREAS ARE BEING REVIEWED SIMULTANEOUSLY

POTENTIAL FOR REVIEW IS LIMITLESS

PNEUMOVAX PRE AND POST BPA

Chart1

9

6

10

10

7

5

9

6

12

10/1/2003 (BPA)

Nov-03

Dec-03

1/1/2004(PVX SHORTAGE)

2/1/2004(SHORTAGE RESOLVED)

Mar-04

Apr-04

5/1/2004(PVX BPA DISABLED)

6/1/2004 (PVX BPA DISABLED)

Jul-04

&A

Page &P

PNEUMOVAX VACCINES FOR AGED 65 AND OVER PATIENTS

Chart3

9Jan-03

6Feb-03

10Mar-03

10Apr-03

7May-03

5Jun-03

9Jul-03

6Aug-03

12Sep-03

10/1/2003 (BPA ON)219

Nov-03170

Dec-03106

1/1/2004(VACCINE SHORTAGE)39

2/1/2004(SHORTAGE RESOLVED)60

Mar-0464

Apr-0439

140

210

051

PNEUMOVAX VACCINES FOR AGED 65 AND OVER PATIENTS

POST BPA

Sheet1

MONTHPNEUMOVAX VACCINES FOR AGED 65 AND OVER PATIENTSPOST BPA

Jan-039

Feb-036

Mar-0310

Apr-0310

May-037

Jun-035

Jul-039

Aug-036

Sep-0312

10/1/2003 (BPA ON)219

Nov-03170

Dec-03106

1/1/2004(VACCINE SHORTAGE)39

2/1/2004(SHORTAGE RESOLVED)60

Mar-0464

Apr-0439

5/1/2004(PVX BPAOFF)14

6/1/2004 (BPA OFF)21

Jul-0451

Sheet2

Sheet3

HGBA1C CONTROL PRE AND POST BPA

Chart1

0.560.14

0.6074218750.1748046875

0.67069892470.1149193548

0.7031802120.1074204947

0.650.12

0.660.13

0.70.1

pre-epic 2002

1q 2003

2q 2003

3q 2003

4q 2003 post bpa

1q 2004

2q 2004

HBA1C UNDER 7.5 PRE BPA

hba1c greater than 9.5

HBA1C OVER 9.5 PRE BPA

HBA1C 9.5 POST BPA

IUFH HBA1C CONTROL

Sheet2

total hba1c testshba1c less than 7.5HBA1C UNDER 7.5 PRE BPAhba1c greater than 9.5HBA1C OVER 9.5 PRE BPAHBA1C 9.5 POST BPA

PRE EPIC 200256%14%

1q 2003102462261%17917%

2q 2003148899867%17111%

3q 2003141599570%15211%

4q 2003 BPA147695918165%12%

1q 20041657109921066%13%

2q 20041717120817470%10%

Sheet3

CERVICAL CANCER SCREENING PER VISIT

Chart1

MONTHMONTHMONTHMONTH

Jan-03Jan-030.0232091051Jan-03

Feb-03Feb-030.0358822074Feb-03

Mar-03Mar-030.0488006617Mar-03

Apr-03Apr-030.051261188Apr-03

May-03May-030.0620025912May-03

Jun-03Jun-030.0541407282Jun-03

Jul-03Jul-030.0529100529Jul-03

Aug-03Aug-030.0595423239Aug-03

Sep-03Sep-030.0531506849Sep-03

10/1/2003 BPA10/1/2003 BPA10/1/2003 BPA0.0758496142

Nov-03Nov-03Nov-030.0750595711

Dec-03Dec-03Dec-030.0728847195

Jan-04Jan-04Jan-040.0701038576

Feb-04Feb-04Feb-040.1061214843

Mar-04Mar-04Mar-040.0781922525

Apr-04Apr-04Apr-040.0696027102

May-04May-04May-040.0741642324

Jun-04Jun-04Jun-040.0742926313

Jul-04Jul-04Jul-040.072226879

Sheet1

MONTH# of patients visitedpap smears

Jan-0344811040.0232091051

Feb-0340411450.0358822074

Mar-0348362360.0488006617

Apr-0349162520.051261188

May-0354033350.0620025912

Jun-0353012870.0541407282

Jul-0352922800.0529100529

Aug-0345012680.0595423239

Sep-0354752910.0531506849

10/1/2003 BPA60914620.0758496142

Nov-0350363780.0750595711

Dec-0355434040.0728847195

Jan-0453923780.0701038576

Feb-0442314490.1061214843

Mar-0469705450.0781922525

Apr-0464944520.0696027102

May-0461624570.0741642324

Jun-0466094910.0742926313

Jul-0471585170.072226879

Sheet2

Sheet3

MBD0006A37B.xls

Chart3

MONTHMONTHMONTHMONTH

Jan-03Jan-030.0232091051Jan-03

Feb-03Feb-030.0358822074Feb-03

Mar-03Mar-030.0488006617Mar-03

Apr-03Apr-030.051261188Apr-03

May-03May-030.0620025912May-03

Jun-03Jun-030.0541407282Jun-03

Jul-03Jul-030.0529100529Jul-03

Aug-03Aug-030.0595423239Aug-03

Sep-03Sep-030.0531506849Sep-03

10/1/2003 BPA10/1/2003 BPA10/1/2003 BPA0.0758496142

Nov-03Nov-03Nov-030.0750595711

Dec-03Dec-03Dec-030.0728847195

Jan-04Jan-04Jan-040.0701038576

Feb-04Feb-04Feb-040.1061214843

Mar-04Mar-04Mar-040.0781922525

Apr-04Apr-04Apr-040.0696027102

May-04May-04May-040.0741642324

Jun-04Jun-04Jun-040.0742926313

Jul-04Jul-04Jul-040.072226879

Sheet1

MONTH# of patients visitedpap smears

Jan-0344811040.0232091051

Feb-0340411450.0358822074

Mar-0348362360.0488006617

Apr-0349162520.051261188

May-0354033350.0620025912

Jun-0353012870.0541407282

Jul-0352922800.0529100529

Aug-0345012680.0595423239

Sep-0354752910.0531506849

10/1/2003 BPA60914620.0758496142

Nov-0350363780.0750595711

Dec-0355434040.0728847195

Jan-0453923780.0701038576

Feb-0442314490.1061214843

Mar-0469705450.0781922525

Apr-0464944520.0696027102

May-0461624570.0741642324

Jun-0466094910.0742926313

Jul-0471585170.072226879

Sheet2

Sheet2

104

145

236

252

335

287

280

268

291

462

378

404

378

449

545

452

457

491

517

NUMBER OF PAP SMEARS PER MONTH

NUMBER OF PAP SMEARS DONE PER MONTH

Sheet3

MAMMOGRAMS PER VISITFemales Ages 40-70

Chart1

Jan-03Jan-030.0877443968Jan-03

Feb-03Feb-030.1083070452Feb-03

Mar-03Mar-030.180712424Mar-03

Apr-03Apr-030.1550353357Apr-03

May-03May-030.1633906634May-03

Jun-03Jun-030.1275531471Jun-03

Jul-03Jul-030.1575252304Jul-03

Aug-03Aug-030.1452685422Aug-03

Sep-03Sep-030.1491712707Sep-03

10/1/2003 (BPA)10/1/2003 (BPA)10/1/2003 (BPA)0.1849315068

Nov-03Nov-03Nov-030.1742528736

Dec-03Dec-03Dec-030.1651048639

Jan-04Jan-04Jan-040.1863100635

Feb-04Feb-04Feb-040.2070484581

Mar-04Mar-04Mar-040.2035211268

Apr-04Apr-04Apr-040.1946232488

May-04May-04May-040.1903000411

Jun-04Jun-04Jun-040.1864470236

Jul-04Jul-04Jul-040.206741573

monthly female visits age 40 to 70

mammograms done for ages 40 to 70 per month

MAMMOGRAMS PER VISIT BY FEMALES AGED 40-70

POST BPA

Sheet1

MONTHmonthly female visits age 40 to 70mammograms done for ages 40 to 70 per monthMAMMOGRAMS PER VISIT BY FEMALES AGED 40-70POST BPA

Jan-0320971840.088

Feb-0319022060.108

Mar-0323024160.181

Apr-0322643510.155

May-0324423990.163

Jun-0323993060.128

Jul-0322793590.158

Aug-0319552840.145

Sep-0323533510.149

10/1/2003 (BPA)24824590.185

Nov-0321753790.174

Dec-0322413700.165

Jan-0422064110.186

Feb-0422704700.207

Mar-0428405780.204

Apr-0426415140.195

May-0424334630.190

Jun-0426714980.186

Jul-0426705520.207

Sheet2

Sheet3

LEAD SCREENING TESTS FOR TWO YEAR OLDS PRE AND POST BPA

Chart1

36

34

57

48

70

46

43

48

69

56

Nov-03

Dec-03

Jan-04

Feb-04

Mar-04

Apr-04

May-04

Jun-04

Jul-04

INSTITUTE FOR URBAN FAMILY HEALTH

LEAD TESTS PRE BPA

Number of Lead Tests Done

Chart2

36Jan-03

34Feb-03

57Mar-03

48Apr-03

70May-03

46Jun-03

43Jul-03

48Aug-03

69Sep-03

5610/1/2003 BPA

Nov-0366

Dec-0367

Jan-0465

Feb-0461

Mar-0458

Apr-0472

May-0445

Jun-0459

Jul-0462

LEAD TESTS PRE BPA

LEAD TESTS POST BPA

Chart3

36Jan-03

34Feb-03

57Mar-03

48Apr-03

70May-03

46Jun-03

43Jul-03

48Aug-03

69Sep-03

5610/1/2003 BPA

Nov-0366

Dec-0367

Jan-0465

Feb-0461

Mar-0458

Apr-0472

May-0445

Jun-0459

Jul-0462

LEAD TESTS PRE BPA

LEAD TESTS POST BPA

Sheet1

monthLEAD TESTS PRE BPALEAD TESTS POST BPA

Jan-0336

Feb-0334

Mar-0357

Apr-0348

May-0370

Jun-0346

Jul-0343

Aug-0348

Sep-0369

10/1/2003 BPA56

Nov-0366

Dec-0367

Jan-0465

Feb-0461

Mar-0458

Apr-0472

May-0445

Jun-0459

Jul-0462

Sheet2

Sheet3

OPHTHALMOLOGY CONSULTS FOR DIABETICS PRE AND POST BPA

Chart2

MONTHMONTH

62Jan-03

135Feb-03

105Mar-03

113Apr-03

105May-03

102Jun-03

119Jul-03

65Aug-03

125Sep-03

10/1/2003 BPA197

Nov-03132

Dec-03143

Jan-04151

Feb-04171

Mar-04201

Apr-04200

May-04168

Jun-04146

Sheet1

MONTH

Jan-0362

Feb-03135

Mar-03105

Apr-03113

May-03105

Jun-03102

Jul-03119

Aug-0365

Sep-03125

10/1/2003 BPA197

Nov-03132

Dec-03143

Jan-04151

Feb-04171

Mar-04201

Apr-04200

May-04168

Jun-04146

Jul-04

Sheet2

Sheet3

Next StepsCONTINUE MULTIPLE MEASURE MONITORINGMONITOR THE USE OF BEST PRACTICE ALERTS BY PROVIDERS AND GUARD AGAINST COMPLACENCYNETWORK WITH OTHER COMMUNITY HEALTH CENTERS IN UNDERSERVED AREAS TO HELP CLOSE THE QUALITY CHASM

Place the second quote from this slide under Outline point #2, bullet #1