Improving Patient Health Outcomesat Primary Care Systems in Clay, WVUsing an Electronic HealthManagement SystemVersion 2.0: 2/11/2008Prepared by: Sarah Chouinard, MD. and Jack L. Shaffer, Jr.
IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHRCase Study for Primary Care SystemsImproving Patient Care Using an EHRBackgroundA number of studies strongly suggest that health care services delivered in the United Statesoften do not meet patient needs. One of these studies indicates that only 50 percent of theindividuals studied received recommended preventive care and only 60 percent receivedrecommended chronic care. Equally troubling was the finding that, of those studied, twentypercent received chronic care that was contraindicated. See: Mark A. Schuster, Elizabeth A.McGlynn, Robert H. Brook (1998), “How Good Is the Quality of Health Care in the United States?”The Milbank Quarterly 76 (4), 517–563.These results were confirmed by a RAND Corporation study that found American adults receivedonly about half (54.9 percent) of recommended medical care in compliance with evidenced-basedguidelines. This study added to the mounting evidence of deficiencies in the U.S. health caresystem, which was highlighted in a 2001 Institute of Medicine report, “Crossing the QualityChasm”, documenting the chasm between the care Americans receive and the care Americansshould expect.There is emerging evidence that electronic health information systems (referred to genericallyherein as “EHR” for “Electronic Health Record”) can have a profound impact on quality of serviceand patient outcomes if implemented in concert with recommended health improvementprocesses. The use of EHR systems permits participants to measure and report externally on anumber of quality indicators and more importantly, to use these results internally to continuallyimprove care delivery by more readily conforming to evidence-based clinical best practices.Use of an EHR system facilitates measurement of outcomes and evaluation of interventions inreal-time rather than a retrospective environment, facilitating continuous improvement of theworkflow and processes of clinical activities. It also facilitates communication and coordination ofcare among care team participants and allows tracking of patient health indicators over time(facilitating health indicator trending through charts and graphs).This case study reviews how the implementation of a population-based EHR along with thechronic care model of care delivery and coordination (referred to herein as the “Care Model”indicating a system of care for chronic conditions based upon a model developed by Ed Wagner,MD, MPH, Director of the MacColl Institute for Healthcare Innovation and employed bycommunity health centers through the Health Disparities Collaborative efforts coordinated byHRSA, see: http://www.improvingchroniccare.org/) is improving the health outcomes for patientsof Primary Care Systems in the rural community of Clay, West Virginia.Primary Care SystemsPrimary Care Systems, Inc., is a Federally Qualified community health center (FQHC) serving theresidents of Clay County, West Virginia, and surrounding areas. Primary Care Systems has twoprimary clinical locations in Clay and Big Otter within Clay County, and three school-based healthcenters at Clay Elementary, Clay Middle and Clay High Schools (with a fourth center planned forthe new Big Otter Elementary School in 2008). Primary Care Systems serves approximately7,200 patients with approximately 30,000 patient encounters annually. Of the patients served,over seventy percent are covered by Medicare or Medicaid or are uninsured. The staff of PrimaryCare Systems currently includes 4 FTE physicians and 4 FTE mid-levels providing a range ofprimary care services, including laboratory, radiology, behavioral health and maternity and well-child services.COMMUNITY HEALTH NETWORK OF WEST VIRGINIA PAGE 2
IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHR(Note: FQHC is a federal designation from the Bureau of Primary Health Care (BPHC) within theHealth Resources and Services Administration (HRSA) of the US Department of Health andHuman Services and the Center for Medicare and Medicaid Services (CMS) that is assigned toprivate non-profit or public health care organizations that serve predominantly uninsured ormedically underserved populations. FQHCs are located in or serve a Federally-designatedMedically Underserved Area/Population (MUA or MUP). FQHCs must operate under a consumerBoard of Directors governance structure, and provide comprehensive primary health, oral, andmental health/substance abuse services to persons in all stages of the life cycle. FQHCs providetheir services to all persons regardless of ability to pay, and charge for services on a Boardapproved sliding-fee scale that is based on patients’ family income and size. FQHCs must complywith Section 330 (of the Public Health Service Act) program expectations/requirements and allapplicable federal and state regulations. FQHCs are also called Community/Migrant HealthCenters (C/MHC), Community Health Centers (CHC), and 330 Funded Clinics.)In 2005, Primary Care Systems began to prepare for the implementation of an EHR system as amember of the Community Health Network of West Virginia (the “Network’) and as a pilot site totest concepts of personal health management and care coordination for the West VirginiaMedicaid program. This preparation involved implementation of the Care Model clinicalprocesses and realignment of clinicians within care teams. Care managers and coordinatorswere trained on disease management processes and patient self-management techniques.These processes were refined over a period of eighteen months and were used to guide theconfiguration of the electronic health information system clinical reminders, health factor reportsand patient education material. In 2006, Primary Care Systems began implementation of anelectronic health management system, starting with care managers and clinical support teammembers and then expanding to physicians. One of the aspects of the project that makesPrimary Care Systems truly unique is that it is the first community health center organization inthe country to successfully implement an adapted version of the Resource and PatientManagement System (“RPMS”) clinical information system developed and used by Indian HealthService. This adapted version of RPMS has been branded as MedLynks™ by the Network.The Medlynks system is a health centered configured version of the RPMS software platform (asoftware platform that is largely in the public domain with a limited number of modules that areproprietary) that has been used by the Indian Health Service to dramatically improve healthoutcomes for tribal populations in a number of ambulatory care settings. MedLynks hastemplates and tools adapted for use in community health centers and can serve as an alternativeto commercial applications to rapidly accelerate the adoption of population-based, patient-centered electronic health information technology.Clinical Outcome MeasuresPrimary Care System, like most FQHC grant recipients, is required to undergo periodic Office ofPerformance Review (“OPR”, formerly called the Primary Care Effectiveness Reviews (“PCER”))which may be combined with Joint Commission on Accreditation of Healthcare Organizations(JCAHO) reviews) to evaluate clinical outcomes and performance. The OPR process requiresthat an FQHC select at least two quality measures from a list of fourteen possible measures andperform a data analysis on those measures for the last three years. To prepare for its periodicOPR evaluation, Primary Care Systems selected two measurements to analyze over the pastthree years: 1. Diabetic patients whose HgBA1c lab results are “under control”. The accepted, standard HgBA1c lab result of seven or less indicates that the patient has their condition under control; anything above seven indicates that the diabetes condition is not being controlled effectively. 2. The percentages of children and adolescents ages 2 thru 19 that have been identified as clinically obese based upon their respective body mass index (BMI) score that have also been referred to weight management counseling.COMMUNITY HEALTH NETWORK OF WEST VIRGINIA PAGE 3
IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHRThese two measures were selected because of some alarming statistics within West Virginia: • West Virginia has historically ranked among the highest nationally for the prevalence of diabetes. Over 10% of West Virginia adults identify themselves as having diabetes (10.9% in 2004 and 10.4% in 2005). • Among diabetic adults, 12% reported not having a recent HbA1c test, 30%-33% did not have a dilated eye exam, and 30%-35% did not have a professional foot exam in the past year. (BRFSS data 04-05). (Source: http://www.wvdhhr.org/bph/oehp/hsc/pubs /BRFSS2004and2005/default.htm) • According to the Robert Wood Johnson Foundation Report, childhood obesity rates have more than tripled in WV from 1980 to 2004, from 5 to 17 percent.The clinical teams of Primary Care Systems had a strong desire to help improve patientoutcomes for diabetics and to assure that children and adolescents with obesity receivedappropriate weight management counseling.Impact on Provider ProductivityIn preparation for the OPR review, Primary Care Systems was required to produce the last threeyears of metrics on both selected measures. In the production of these metrics, the clinical teamnoted significant differences in the results during the period from 2005 to 2007. A careful analysisof the data and clinical process changes suggested several factors influencing the favorabletrends in these outcomes.The clinic characterized 2005 as a “normal” baseline year for them. During this period, PrimaryCare Systems had a consistent number of providers; they were using paper charts, and wereoperating primarily as they had in the past as the clinical team started to evaluate the impactimplementation of the Care Model would have on clinical practices.In 2006, two disruptive events occurred within Primary Care Systems: 1) – The clinic lost twophysicians, and 2) – the clinicians began to implement MedLynks. With the loss of twophysicians, there was a productivity loss that occurred. With the implementation of MedLynks,that productivity loss was amplified. As with any EHR implementation, there is an initial drop inproductivity due to the learning curve required to integrate the EHR into the patient treatmentprocess. Interestingly enough, studies tend to show that if a clinic or health center is notoperating properly, the health outcomes of chronically-ill patients do not improve and may evendecline. As Dr. Sarah Chouinard - the Medical Director of Primary Care Systems noted, “if youhave an unhealthy clinic, you will have unhealthy patients.”In 2007, Primary Care Systems returned to a “normal” level of productivity. The clinic replacedthe two providers and completed full implementation of MedLynks.Diabetic patients whose HgBA1c lab results indicate “control”From a health outcome measurement standpoint, the HgBA1c is a very good measurement toolsince it is based upon an actual blood test. It is not a “soft measure” like counseling where themeaning of the measure could be somewhat ambiguous. Although soft measures are valuable,they are not as quantifiable in evaluating direct impact on patient health as these laboratory testresults.COMMUNITY HEALTH NETWORK OF WEST VIRGINIA PAGE 4
IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHR After EHR Implementation Diabetes HgBA1c 90.00% 79.30% 80.00% 68.50% 70.00% Count: 59.30% 149 60.00% Count: 98 50.00% Count: 86 40.70% 40.00% 31.50% 30.00% 20.70% 20.00% Count: Count: 45 59 Count: 10.00% 39 0.00% 2005 2006 2007 HGBA1C<7.0 Percentage Uncontrolled PercentageIn evaluating this specific measure, the 2005 number of 68.5% of the diabetic population ofPrimary Care System patients whose condition is “controlled” (i.e., with a HgBA1c at or below 7)was a good outcome - slightly above the West Virginia average. The national average issomewhat higher at around 70%. For 2006, the lower numbers can be attributed to thedisruptions mentioned above that were occurring at the clinic. In 2007, Primary Care Systemachieved an increase to nearly 80% in the number of patients whose diabetic condition wascontrolled. The number of diabetic patients being evaluated also increased by 33% from 2005 to2007. The patient population base increase was directly attributable to the use of the EHR inmore uniformly capturing these diabetic patients for care management.The improvement in outcomes from 2006 to 2007 is directly related to the use of information fromthe EHR and the implementation of the care model. In evaluating these outcomes, Dr. Chouinardcommented, “These increases are not because we suddenly got smarter or practiced medicine ina different way – it’s not like we all of sudden learned how to use insulin. The increase was dueto the clinical staff being able to quickly run reports and following up with patients.”By using MedLynks, the clinic was able to easily identify patients that were missing a recentHgBA1c test. Without an EHR, tracking this information is difficult. This type of tracking in apaper-based chart system requires using reports from a practice management or registry systembased upon ICD or CPT codes (that tend to reflect visit purpose more than overall prevalence ofchronic conditions and then having a staff member laboriously perform chart audits for thespecific lab. With the EHR, the clinic captures all meaningful patient clinical information, not justa subset, and the capturing of the pertinent data is integrated within the patient treatment regime.The EHR also allowed care managers to work with patients to establish self management goalsfor diet and exercise, two important elements of therapeutic lifestyle change this have proven vitalin achieving and sustaining good control of blood sugar levels for diabetic patients.Obese children and adolescents ages 2 – 19 referred to counselingAnother persuasive outcome improvement attributable to use of the EHR by Primary CareSystems was the increase in the number of children and adolescents ages 2 thru 19 that havebeen identified as clinically obese based upon their respective body mass index (BMI) score thathave also been referred to weight management counseling.COMMUNITY HEALTH NETWORK OF WEST VIRGINIA PAGE 5
IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHR Obesity DX for Ages 2 – 19 (with and without counseling) 2005, 2006, and 2007 8 10 2 23 44.4% 55.6% 8.0% 92.0% 2005 2006 YES COUNT NO COUNT YES COUNT NO COUNT After EHR Implementation 156 0 100% 0% 2007 YES COUNT NO COUNTIn 2005, Primary Care Systems only captured the BMI statistic on 18 patients that were childrenor adolescents that met the targeted class (i.e., obese). Of those 18 patients, only 8 werereferred to weight management counseling. In 2006, the overall capture rate of BMI metricsincreased slightly, however, the referrals decreased to 8%. This percentage indicates that only 2of the 25 obese adolescents or children identified in 2006 were referred to counseling. Uponanalyzing the reason for this decline between 2005 and 2006, it was discovered that much of thedecline could be attributed to the loss of one specific provider who practiced at one of the schoolbased centers with a particular interest in childhood and adolescent obesity.In 2007, the numbers increased dramatically. The entire population in this category increasednearly 10 fold, from 18 in 2005 to 156 in 2007. The percentage being referred went to 100%.These increases – particularly the increase in the number of patients in the targeted class – canbe directly linked to use of the EHR within Primary Care Systems.Before implementation of the EHR, a nurse or care manager had to perform a specific calculationto determine and record a patient’s BMI. With the adoption of the EHR, the BMI on each patientis calculated and stored automatically with every visit – it is not an extra step for someone toperform. Once the data was captured within the EHR, it was a simple procedure to producereports showing the patients that fell into the specific categories and to use these reports forfollow up and referral to counseling. The EHR also allowed for the creation of clinical remindersto aid the nurse or clinical coordinator to recommend counseling to these patients at the time ofcare, during the patient visit rather than retrospectively based upon chart audits (as was the casepre-EHR implementation).The improvement reflected in this measure demonstrates how an EHR can aid in the qualityimprovement process by helping to establish a standard of consistent care throughout anCOMMUNITY HEALTH NETWORK OF WEST VIRGINIA PAGE 6
IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHRorganization. Without an EHR, these evidenced-based best practices are often only consistentlyemployed by specific providers with a particular passion for the issue or targeted condition.EHR as a tool in a processOne inference that can be drawn from these outcome results is that improvements were notoccurring because the patients just weren’t coming to the clinic. The clinic would perform anHgBA1c test on the patient and then perhaps would not see the patient again for a year (ormore). This was largely due to the reactive nature of most health care engagements and theacute care nature of most health care delivery. Most encounters in the old delivery system ofPrimary Care Systems, like much of primary care in general, was based upon a patient-initiatedinteraction with a specific emergent condition necessitating care, relegating many unmet needs toa “get to it when we can” approach based upon 15 to 20 minute clinical increments withphysicians or mid-level providers.One of the enormous benefits of a population-based EHR is identifying those patients who arenot up-to-date on recommended or required care. The EHR allows the clinical care teams to beproactive in engaging patients in preventive and chronic disease self management. As notedabove, this requires a two-fold approach utilizing care management teams empowered andinformed with health information from the EHR.In the HgBA1c improvement process, Primary Care Systems generated periodic reports ofpatients who had an HgBA1c or other diabetic-type lab result at anytime in the clinic. Once apatient was on this list, the care teams began to contact those patients by generating letters andmaking phone calls over several months. During the first month a person was listed on thereport, they were mailed a letter requesting that the patient come to the clinic for examination.The second month that patient was listed on the report, the patient was sent a follow-up letterasking that they schedule a visit. If a patient remained on the list after sixty days, they received aphone call from the clinical coordinator. After ninety days, the attending doctor called the patientrequesting a follow-up visit. The process would have been too cumbersome prior toimplementation of MedLynks, because these lists had to be generated manually.Primary Care Systems also implemented processes and work flow changes to bring negativehealth factors to the patient’s attention during a visit. Prior to EHR implementation, in most visits,the physician would only deal with the primary purpose of the visit (i.e., the immediate healthconcern that triggered the visit). With the EHR and the clinical reminders integrated intoMedLynks, the triage nurses and care managers of Primary Care Systems could bring negativehealth factors such as an adverse BMI (indicating obesity or an overweight condition) to theattention of the patient. The experience at Primary Care Systems confirms studies that havefound that repeatedly addressing these chronic conditions during clinical encounters canempower and motivate a patient to take charge of his or her health and make necessary lifestylechanges.Another example of the power of these clinical reminders in improving health outcomes is in thearea of tobacco cessation. Prior to implementation of the EHR, the rate of documentedcounseling for tobacco cessation at Primary Care System was under 20%. During the first year,by using the clinical reminder system, the care teams achieved a rate of documented counselingfor tobacco cessation of one hundred percent. The impact that these changes have on theindividual lives of the patients is best exemplified by a patient that had been a lifetime smoker, butrecently was successful in her quest to kick the habit through counseling and patient self-management guided by the reminder system and the work of a dedicated care manager. Whatwere occasional successes, like that of the patient described above, now are more commonplacethrough the use of MedLynks. It is said that information is power and applied clinical informationat the point of care is a powerful force for health improvement.COMMUNITY HEALTH NETWORK OF WEST VIRGINIA PAGE 7
IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHRNext steps: Future ImprovementsNow that Primary Care Systems is making significant progress in the delivery of quality healthcare, the clinical teams plan to expand their efforts to more patients with chronic conditions.The team intends to focus on gaps in care such as identifying asthma patients with persistentasthma that are not using appropriate medications, such as an inhaled steroid. Havingadolescent asthmatic patients who need controlling medications on a steroid has been clinicallyproven to save lives and the physicians at Primary Care Systems believe that they candramatically improve upon their outcomes in this category in much the same way they have in theaforementioned measures.They also plan on developing reports and metrics for all other standard nationally-recognizedclinical outcome measures. Dr. Chouinard has summarized the commitment of the clinical staff atPrimary Care Systems this way: “The more we can measure and evaluate, the more we canimprove the care for our patients. As we master the use of this system, we are excited about thelevel of improvement we can achieve for our patients with these tools as we move forward.”SummaryIt is important to recognize that an EHR is only one component in the health improvementprocess. This case study shows that an EHR is a tool that can produce dramatic healthimprovements if properly applied. In this case study, the particular tool had clinical reminders anda number of other care management applications integrated to enable the care teams at PrimaryCare Systems to deliver better health care; however, much of the health improvement wasachieved by the care teams effectively using the tools and the information that an EHR provides.A number of studies have shown that an EHR implementation will not alone produce substantiallybetter outcomes.As shown by this case study, Primary Care Systems is making significant strides in improving thequality of the care it is delivering to its patients through the effective use of an EHR and theadoption of the clinical care model. Although the implementation of either singularly could havesome impact on improved health outcomes, the most significant gains are made when the careprocess realignment and the information and management tools are integrated and implementedtogether.COMMUNITY HEALTH NETWORK OF WEST VIRGINIA PAGE 8