Most agree that electronic health records (EHRs) can cut health-care costs and reduce errors. However, only a few providers have adopted EHRs because deployment costs are often prohibitive. The New York City Department of Health and Mental Hygiene (DOHMH) is taking the bull by the horns and helping physicians deploy and use EHR systems.
Through its Primary Care Information Project (PCIP), the department pays some costs of deploying EHR systems. The goal is to boost EHR adoption among New York City doctors and give them the tools they need to improve patient care.
"We believe the absence of consistent evidence-based care in primary practice is a public health problem," said Farzad Mostashari, assistant commissioner of the DOHMH.
A focus on chronic diseases and common killers like high blood pressure and diabetes can save lives and result in a healthier population, making it a matter of public health, he explained. However, in some ways, agencies like the DOHMH are limited to combat these common issues.
"We don't directly provide health care. We don't pay for or even regulate health care," said Mostashari. "Our solution was to try to change the decision-making context for the clinicians by providing them with electronic health records that have a public health perspective baked into it."
Doctors have been reluctant to adopt EHRs because the expense and inconvenience come with little payback.
"This transition is laborious and it's difficult to change one's workflows completely and every aspect of their day. This also can be expensive for practices to adopt health records, and only a small portion of the benefits accrue to the physician who's expected to put all the money in," Mostashari explained. "So there's been a market failure in this industry."
The result, he said, is that only 2 percent of U.S. practices have a full-featured EHR system in place. Even when practices use EHRs, health goals aren't necessarily built into the product. To improve adoption and help physicians handle these public health measures, the DOHMH is working with providers to roll out EHRs with tools that support public health goals -- at minimal expense to providers.
The city assists doctors whose Medicaid or uninsured patients constitute more than 10 percent of their total visitors, as long as the physicians are willing to work with the city on quality improvement. According to Mostashari, 1,100 doctors are participating, with several hundred more in the pipeline. Participants include small practices, community health centers and hospital outpatient departments.
The system has alerts and tools that help physicians better manage targeted health conditions, pull patient reports and see how they handle certain conditions compared to other physicians who use the system.
"It pops up with alerts. It allows them to act on it when the patient is there. It also allows the physician to see at the end of the month how they're doing against those alerts -- compare themselves," said eClinicalWorks CEO Girish Kumar Navani. "That's a step up over most EHR deployments."
The DOHMH helps physicians financially by covering software and license costs, project management, and two years of maintenance and support from software provider eClinicalWorks. Practices must buy their own hardware and contribute $4,000 to a quality improvement fund that provides program support. However, the department has identified several high-priority areas: Harlem, central Brooklyn and the south Bronx. For doctors in those areas, the DOHMH waives the $4,000 contribution and provides a hardware package worth approximately $10,000. Mostashari said more than half of small practices and community health centers in the three areas have signed on.
When interviewed in February, Mostashari said approximately $20 million had been spent on the project, he said, with funding from the city, New York state, the Centers
for Disease Control and Prevention, and the federal Agency for Healthcare Research and Quality.
The system also will support larger public health goals by giving the DOHMH de-identified reports on patients who visit participating physicians. Besides letting doctors see how their patients compare, the department hopes the data will help identify outbreaks and quality-of-care trends.
However, Mostashari and Navani made it clear that the DOHMH doesn't collect patient-level data.
"We don't need it. We don't want it. We don't get it," said Mostashari, adding that only de-identified reports are collected.
"We'd only get summarized counts for those various measures," he said. For instance, the health department could only see that seven patients out of 20 have a flulike illness.
The department collects data to ensure providers use the system as required by their contracts, gauge key quality of care indicators and monitor illness trends in the community.
As a government agency, Mostashari said it was important to collect only the necessary data.
"We felt that in terms of earning and keeping the public's trust, we could not afford to have even the possibility of a large data breach," he said.
Although EHR deployment requires an upfront time and cost investment, some participants said EHRs offer better convenience and lower costs. Dr. Michele C. Reed, who has practices in Queens and Long Island, said she jumped at the chance to participate.
Reed said she likes the convenience EHRs provide. Being able to log in remotely has been handy, she added.
If Reed must leave the office, she can log in from home later to finish her notes. "You can log in to the system and do it at home, as opposed to waiting until the next day and maybe forgetting what you might have discussed with a patient."
Remote login also helps when Reed is on call because she doesn't have to rely on patients for prescription or treatment information. She can look up the data from anywhere.
Being able to pull reports on all of her patients and look at historical data helps her provide better care.
EClinicalWorks has a training site, and Reed made sure her staff had access to it before training began.
To accommodate the deployment learning curve required, Reed said her practice began implementing the system during the off-peak season.
"We knew we were going to be slow, so that's why we planned the training to occur right before school started in the last week of August, beginning of September."
Now that the system is in place, she said being paperless has been a boon to the office's productivity, allowing her to submit prescriptions in less than a minute, pull patient files on the spot and quickly return calls.
"Because we are a smaller practice, we don't have to delegate someone to pull charts when someone leaves a message, so doctors are able to return calls a lot faster as opposed to waiting until we get a break in our schedule and going back to our room," she said. "All of our rooms have computers, so if I'm sitting in the exam room waiting for our next patient, I can just quickly place a phone call to a patient because everything is right there, I don't have to wait until someone hands me a chart."
She said the office has yet to launch its patient portal, but soon patients can view their health information, make appointments or change their personal information online.
One thing the EHR systems being offered by the health department won't do -- at least, not yet
-- is share data with other providers. The health department won't facilitate data sharing directly, but will link providers with regional health information organizations (RHIOs) when the organizations are ready.
"There has been more than $100 million of investment in New York state on the development of health information exchange protocol systems and organizations and the RHIOs," Mostashari said. "Our approach has been to not try to reinvent the wheel, but use that infrastructure that's developed when it becomes available to our practices -- to communicate with each other and with other hospitals and practices outside of our network."
Mostashari said he hopes the city's PCIP will serve as a model for other jurisdictions and the country. He urged governments to focus on quality of care as stimulus dollars become available for health IT.
"Government agencies across the board are facing some very challenging times. I would urge my colleagues in other locales or jurisdictions to engage with this opportunity around health IT and the stimulus funding that's available to bring that public perspective and expectation of getting public benefit from the investment of taxpayer dollars," Mostashari said, "because absent a strong perspective that we can provide, there is a definite risk that the result of this is going to be a lot of health information technology, but not much improvement in the public's health."
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