Primary Care Information Project Research Articles

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

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

Elevated Pertussis Reporting in Response to 2011-2012 Outbreak, New York City, New York, USA.

Elevated Pertussis Reporting in Response to 2011-2012 Outbreak, New York City, New York, USA.

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

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

Applied Use of Composite Quality Measures for EHR-enabled Practices.

Introduction:The Primary Care Information Project (PCIP) of the New York City Department of Health and Mental Hygiene has been assisting providers to implement health information technology such as electronic health records (EHRs) since its founding in 2005. Currently, all practices affiliated with PCIP are offered technical support services in order to improve the use of the EHR. We studied the performance of clinical practices on EHR-derived Composite Quality Measures (CQMs) over time. Because specific EHR functionalities are important to calculating the quality measures, we hypothesize that performance on each of the CQMs will differ according to the EHR functionalities, and that this can inform the process of developing targeted technical assistance for the practices.Methods:We created four CQMs: (1) Screening, (2) Assessment, (3) Control-BP, and (4) Control-Other. Using data from 93 practices, we identified three tertiles of CQM performance (premier, average, and low tiers) for each measure. A scatterplot of CQMs in 2010 versus 2011 was used to examine the individual movement of practices by tier. A dependent t-test compared the change in mean CQMs, and a chi-square test examined the association between the score and performance tier changes.Results:Over a one-year period, low tier practices demonstrated the highest gains, average tier practices had modest gains, and premier tier practices had gains in some measures, but losses in others. On the Screening CQM 70 percent of practices remained within the same tier, with 60 percent on Assessment, 52 percent on Control-BP, and 38 percent on Control-Other; the Control-Other group showed the greatest improvement.Discussion:By considering EHR functionalities associated with each of the four CQMs, we suggest that technical assistance can be better targeted to low-tier performing practices. In addition, there is still the potential for improvement over time at practices more familiar with key functionalities.

Evaluating the New York State 2010 HIV testing law amendments: context, challenges, and conclusions.

Evaluating the New York State 2010 HIV testing law amendments: context, challenges, and conclusions.

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

BackgroundIn 2009, the American Recovery and Reinvestment Act apportioned $643 million for a Health Information Technology Extension Program, which established Regional Extension Centers (RECs) to support the implementation and use of electronic health records (EHRs). ProblemLittle is known, however, about how RECs should assist in EHR implementation and how they should structure ongoing support. GoalsThe purpose of this paper is to describe physicians' experiences with the Primary Care Information Project (PCIP), an REC run by the New York City Department of Health and Mental Hygiene. StrategyWe interviewed 17 physicians enrolled in PCIP to understand the role of the EHRon quality of care and their experience with technical assistance from PCIP. ResultsAll physicians stated that they felt that the EHR improved the quality of care they delivered to their patients particularly because it helped them track patients. All the physicians found technical assistance helpful but most wanted ongoing assistance months or years after they adopted the EHR. Implications•Physicians believe that both the EHR and ongoing technical assistance are important determinants of quality improvement.•RECs should consider models that provide ongoing technical assistance at regular intervals.

Assessing capacity and disease burden in a virtual network of New York City primary care providers following Hurricane Sandy.

Urban contexts introduce unique challenges that must be addressed to ensure that areas of high population density can function when disasters occur. The ability to generate useful data to guide decision-making is critical in this context. Widespread adoption of electronic health record (EHR) systems in recent years has created electronic data sources and networks that may play an important role in public health surveillance efforts, including in post-disaster situations. The Primary Care Information Project (PCIP) at the New York City Department of Health and Mental Hygiene has partnered with local clinicians to establish an electronic data system, and this network provides infrastructure to support primary care surveillance activities in New York City. After Hurricane Sandy, PCIP generated several sets of data to contribute to the city's efforts to assess the impact of the storm, including daily connectivity data to establish practice operations, data to examine patterns of primary care utilization in severely affected and less affected areas, and data on the frequency of respiratory infection diagnosis in the primary care setting. Daily patient visit data from three heavily affected neighborhoods showed the health department where primary care capacity was most affected in the weeks following Sandy. Overall transmission data showed that practices in less affected areas were quicker to return to normal reporting patterns, while those in more affected areas did not resume normal data transmissions for a few months. Rates of bronchitis increased after Sandy compared to the two prior years; while this was most likely attributable to a more severe flu season, it demonstrates the capacity of primary care networks to pick up on these types of post-emergency trends. Hurricane Sandy was the first disaster situation where PCIP was asked to assess public health impact, generating information that could contribute to aid and recovery efforts. This experience allowed us to explore the strengths and weaknesses of ambulatory EHR data in post-disaster settings. Data from ambulatory EHR networks can augment existing surveillance streams by providing sentinel population snapshots on clinically available indicators in near real time.

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

IntroductionPrior research has shown that provider positive attitudes about EHRs are associated with their successful adoption. There is no evidence on whether comfort with technology and more positive attitudes about EHRs affect use of EHR functions once they are adopted. MethodsWe used data from a survey of providers in the Primary Care Information Project, a bureau of the New York City Department of Health and Mental Hygiene and measures of use from their EHRs. The main predictor variables were scores on three indices: comfort with computers, positive attitudes about EHRs, and negative attitudes about EHRs. The main outcome measures were four measures of use of EHR functions. We used linear regression models to test the association between the three indices and measures of EHR use. ResultsThe mean comfort with computers score was 2.37 (SD 0.53) on a scale of 1–3 with 3 being the most comfortable. The mean positive attitude score was 2.74 (SD 0.40) on a scale of 1–3 with 3 being more positive. The mean negative attitude score was 1.81 (SD 0.54) on a scale of 1–3 with 3 being more negative. Within the first twelve months of having the EHR, 59.5% of visits had allergy information entered into a structured field, 64.8% had medications reviewed, and 74.3% had blood pressured entered. Among visits with a prescription generated, 24.5% had prescriptions electronically prescribed. In multivariate regression analysis, we found no significant correlations between comfort with computers, positive attitudes about EHRs, or negative attitudes about EHRs and any of the measures of use. DiscussionComfort with computers and attitudes about EHRs did not predict future use of the EHR functions. Our findings suggest that meaningful use of the EHR may not be affected by providers׳ prior attitudes about EHRs.

Health Information Technology and the Primary Care Information Project

A letter to the editor is presented in response to the article Electronic Health Records and U.S. Public Health: Current Realities and Future Promise by D. J. Friedman, P. Gibson and D. A. Ross in a 2013 issue.

Friedman and Parrish Respond

We thank Kaye et al. for their helpful comments on our article. As they indicate, the New York City Department of Health and Mental Hygiene’s Primary Care Information Project, its Hub Population Network, and the associated NYC Macroscope are accomplishing three key steps in utilizing electronic health records for public health intervention and population health information: (1) collecting essential indicators from patients, (2) aggregating those indicators at the population level, and, especially encouraging, (3) validating the representativeness of the collected data at the population level. We congratulate Kaye and her colleagues, and we look forward to reviewing the results of their efforts.

Early Assessment of Health Care Utilization Among a Workforce Population With Access to Primary Care Practices With Electronic Health Records

This study assesses the health care costs and utilization among labor union members from 2008 to 2010 and compares whether members accessing primary care providers participating in a public health city program, the Primary Care Information Project (PCIP), had different health care usage or cost patterns. Using claims data, the number of hospital inpatient services utilized decreased by 16 per 100 members among those with chronic conditions accessing PCIP providers, whereas members seeing non-PCIP providers increased by 15 per 100 members. Access to providers participating in a population health initiative was associated with lower utilization of inpatient services and overall costs.

Patient-Centered Medical Home Among Small Urban Practices Serving Low-Income and Disadvantaged Patients

Research on the patient-centered medical home (PCMH) model and practice redesign has not focused on the unique challenges and strengths of very small primary care practices serving disadvantaged patient populations. We analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model that exist in such practices participating in the Primary Care Information Project (PCIP) of the New York City Department of Mental Health and Hygiene. We obtained descriptive data, focusing on PCMH, for 94 primary care practices with 5 or fewer clinicians serving high volumes of Medicaid and minority patient populations in New York City. Data included information extracted from PCIP administrative data and survey data collected specifically for this study. Survey results indicated substantial implementation of key aspects of the PCMH among small practices serving disadvantaged patient populations, despite considerable potential challenges to achieving PCMH implementation. Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH. Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. The use of flexible, less formal strategies is important to keep in mind when considering implementation and assessment of PCMH-like initiatives in small practices.

Effects of automated immunization registry reporting via an electronic health record deployed in community practice settings

Among the expected benefits of electronic health records (EHRs) is increased reporting of public health information, such as immunization status. State and local immunization registries aid control of vaccine-preventable diseases and help offset fragmentation in healthcare, but reporting is often slow and incomplete. The Primary Care Information Project (PCIP), an initiative of the NYC Department of Health and Mental Hygiene, has implemented EHRs with immunization reporting capability in community settings. To evaluate the effect of automated reporting via an EHR on use and efficiency of reporting to the NY Citywide Immunization Registry, we conducted a secondary analysis of 1.7 million de-identified records submitted between January 2007 and June 2011 by 217 primary care practices enrolled in PCIP, pre and post launch of automated reporting via an EHR. We examined differences in records submitted per day, lag time, and documentation of eligibility for subsidized vaccines. Mean submissions per day did not change. Automated submissions of new and historical records increased by 18% and 98% respectively. Submissions within 14 days increased from 84% to 87%, and within 2 days increased from 60% to 77%. Median lag time decreased from 13 to 10 days. Documentation of eligibility decreased. Results are significant at p<0.001. Significant improvements in registry use and efficiency of reporting were found after launch of automated reporting via an EHR. A decrease in eligibility documentation was attributed to EHR workflow. The limitations to comprehensive evaluation found in these data, which were extracted from a registry initiated prior to widespread EHR implementation suggests that reliable evaluation of immunization reporting via the EHR may require modifications to legacy registry databases.

Predictors of success for electronic health record implementation in small physician practices

The federal government is promoting adoption of electronic health records (EHRs) through financial incentives for EHR use and implementation support provided by regional extension centers. Small practices have been slow to adopt EHRs. Our objective was to measure time to EHR implementation and identify factors associated with successful implementation in small practices receiving financial incentives and implementation support. This study is unique in exploiting quantitative implementation time data collected prospectively as part of routine project management. This mixed-methods study includes interviews of key informants and a cohort study of 544 practices that had worked with the Primary Care Information Project (PCIP), a publicly funded organization that since 2007 has subsidized EHRs and provided implementation support similar to that supplied by the new regional extension centers. Data from a project management database were used for a cohort study to assess time to implementation and predictors of implementation success. Four hundred and thirty practices (79%) implemented EHRs within the analysis period, with a median project time of 24.7 weeks (95% CI: 23.3 - 26.4). Factors associated with implementation success were: fewer providers, practice sites, and patients; fewer Medicaid and uninsured patients; having previous experience with scheduling software; enrolling in 2010 rather than earlier; and selecting an integrated EHR plus practice management product rather than two products. Interviews identified positive attitude toward EHRs, resources, and centralized leadership as additional practice-level predictors of success. A local initiative similar to current federal programs successfully implemented EHRs in primary care practices by offsetting software costs and providing implementation assistance. Nevertheless, implementation success was affected by practice size and other characteristics, suggesting that the federal programs can reduce barriers to EHR implementation but may not eliminate them.

Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records

The 2009 American Recovery and Reinvestment Act spurred adoption of electronic health records (EHRs) in the United States, through such measures as financial incentives to providers through Medicare and Medicaid and regional extension centers, which provide ongoing technical assistance to practices. Yet the relationship between EHR adoption and quality of care remains poorly understood. We evaluated the early effects on quality of the Primary Care Information Project, which provides subsidized EHRs and technical assistance to primary care practices in underserved neighborhoods in New York City, using the regional extension center model. We found that just general participation in, or exposure to, the project was not enough to improve quality of care. It took sustained exposure on the part of these practices and technical assistance to them before they demonstrated improvement on measures of care most likely to be affected by the use of electronic health records, such as cancer screenings and care for patients with diabetes. Participating in the Primary Care Information Project for nine or more months was associated with significantly improved quality, but only for this limited group of quality measures and only for physicians receiving extensive technical assistance.

Validity of electronic health record-derived quality measurement for performance monitoring

BackgroundSince 2007, New York City's primary care information project has assisted over 3000 providers to adopt and use a prevention-oriented electronic health record (EHR). Participating practices were taught to re-adjust their workflows to use the EHR built-in population health monitoring tools, including automated quality measures, patient registries and a clinical decision support system. Practices received a comprehensive suite of technical assistance, which included quality improvement, EHR customization and configuration, privacy and security training, and revenue cycle optimization. These services were aimed at helping providers understand how to use their EHR to track and improve the quality of care delivered to patients.Materials and MethodsRetrospective electronic chart reviews of 4081 patient records across 57 practices were analyzed to determine the validity of EHR-derived quality measures and documented preventive services.ResultsResults from this study show that workflow and documentation habits have a profound impact on EHR-derived quality measures. Compared with the manual review of electronic charts, EHR-derived measures can undercount practice performance, with a disproportionately negative impact on the number of patients captured as receiving a clinical preventive service or meeting a recommended treatment goal.ConclusionThis study provides a cautionary note in using EHR-derived measurement for public reporting of provider performance or use for payment.

Health Information Systems in Small Practices: Improving the Delivery of Clinical Preventive Services

Despite strong evidence that clinical preventive services (CPS) reduce morbidity and mortality, CPS performance has not improved in adult primary care. In addition to implementing electronic health records (EHRs), key factors for improving CPS include providing actionable information at the point of care, technical support staff, and quality-improvement assistance. These resources are not typically available in small practices. Estimate the impact on CPS delivery after a software upgrade to embed a clinical decision support system and practice-level quality-improvement support services. Practices were recruited from the Primary Care Information Project, a citywide initiative assisting practices adopt health information technology. Data were collected in 2009 and 2010, and analyses were conducted in 2010 and 2011. Across two time periods, receipt of CPS was calculated for 56 practices. Period 1 measured CPS delivery 2-37 months following implementation of an EHR. Period 2 measured CPS delivery within the first 6 months after an EHR software upgrade. Substantial increases in the delivery of selected CPS were observed after the EHR software upgrades. Blood pressure control for patients with hypertension increased from 46.0% to 54.8%. Breast cancer screening, recorded BMI, and HbA1c testing for patients with diabetes also increased. More than half of the practices increased their patients' blood pressure control, recorded BMI, breast cancer screening, and HbA1c screening by ≥5 percentage points. Delivery of CPS can increase in small primary care practices that implement an EHR that includes comprehensive quality-improvement support.

In response to: Electronic health records in small physician practices: availability, use, and perceived benefits

In their report ‘Electronic health records in small physician practices: availability, use, and perceived benefits’, Rao et al correctly point out many of the challenges these small practices face when adopting electronic health records (EHR).1 As part of New York City's Primary Care Information Project, we have deployed EHRs to over 2550 providers in NYC, including over 400 small physician practices. In order to get to a point …

Tracking the delivery of prevention-oriented care among primary care providers who have adopted electronic health records.

The Primary Care Information Project is a New York City initiative aimed at improving population health through the improved delivery of preventive care. It has assisted with the adoption of a fully functional electronic health record (EHR) in over 300 primary care practices. Practices with EHRs automatically transmit summary data that can be used to track population health indicators for recommended preventive care. Early analysis, focusing on small practices with fewer than 10 providers serving Medicaid and uninsured populations, showed increases in the delivery of recommended services of 0.1-2.4% per month (p ≤ 0.05). However, measurement of preventive care across this population is limited by some inconsistency of data transmission. This study shows that EHRs can be used to track the delivery of recommended preventive care across small primary care practices serving lower income communities in which few data are generally available for assessing population health.

Resting functional connectivity between the hemispheres in childhood absence epilepsy

The fundamental mechanisms by which childhood absence epilepsy (CAE) changes neural networks even between seizures remain poorly understood. During seizures, cortical and subcortical networks exhibit bihemspheric synchronous activity based on prior EEG-fMRI studies. Our aim was to investigate whether this abnormal bisynchrony may extend to the interictal period, using a blood oxygen level-dependent (BOLD) resting functional connectivity approach. EEG-fMRI data were recorded from 16 patients with CAE and 16 age- and gender-matched controls. Three analyses were performed. 1) Using 16 pairs of seizure-related regions of interest (ROI), we compared the between-hemisphere interictal resting functional connectivity of patients and controls. 2) For regions showing significantly increased interhemispheric connectivity in CAE, we then calculated connectivity to the entire brain. 3) A paired-voxel approach was performed to calculate resting functional connectivity between hemispheres without the constraint of predefined ROIs. We found significantly increased resting functional connectivity between hemispheres in the lateral orbitofrontal cortex of patients with CAE compared to normal controls. Enhanced between-hemisphere connectivity localized to the lateral orbitofrontal cortex was confirmed by all 3 analysis methods. Our results demonstrate abnormal increased connectivity between the hemispheres in patients with CAE in seizure-related regions, even when seizures were not occurring. These findings suggest that the lateral orbitofrontal cortex may play an important role in CAE pathophysiology, warranting further investigation. In addition, resting functional connectivity analysis may provide a promising biomarker to improve our understanding of altered brain function in CAE during the interictal period.