Using EHRs to Improve Cascades in Primary Care …...Using EHRs to Improve Cascades in Primary Care...

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Using EHRs to Improve Cascades in Primary Care Settings Benjamin Young, MD PhD International Association of Providers of AIDS Care, Washington DC Josef Korbel School of International Studies, University of Denver

Transcript of Using EHRs to Improve Cascades in Primary Care …...Using EHRs to Improve Cascades in Primary Care...

Page 1: Using EHRs to Improve Cascades in Primary Care …...Using EHRs to Improve Cascades in Primary Care Settings Benjamin Young, MD PhD International Association of Providers of AIDS Care,

Using EHRs to Improve Cascades in Primary Care Settings

Benjamin Young, MD PhDInternational Association of Providers of AIDS Care, Washington DCJosef Korbel School of International Studies, University of Denver

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OVERVIEW

• Cascades

• Electronic Health Records and HIV

• Overview of the Alliance of Chicago• HIV EHRs • Preview of future HER plans

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CASCADES

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CASCADES:ENGAGEMENT IN CARE

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Engagement in HIV Care and Treatment :USA

Gardner, et al., Clin Infect Dis 2011

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Refocusing Engagement in Care and Treatment

Those not:

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ELECTRONIC HEALTH RECORDS AND HIV CARE

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RECOMMENDATIONS FOR ADVANCINGENGAGEMENT IN CARE

Develop integrated health informatics systems to collect real-time, actionable, patient-level surveilance of HIV testing and engagement in care activities

Mugavero, Norton, Saag. Clin Infect Dis 201

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• Estimates of differences between EHR- and paper-based practices for 27,207 adults in 46 clinics.

• Composite standards:– diabetes care 35.1% higher at EHR sites (P<0.001)– Outcomes 15.2% higher at EHR sites (P<0.005)

• Use of EHRs may improve quality of care

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• Urban HIV outpt facility in Kampala, Uganda, implemented EMR

• Compared 2,383 visits (from 100 pts; paper) to 34,957 visits (from 10,920 pts, EMR)

• Decreased proportion of reporting errors from:• OIs 66% to 2%• ART toxicity 52% to 3.5%• Reasons for ART interruption 83% to 12.5%• Reasons for ART switch 94% to 0.9%

• EMR well accepted by providers

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EMR AND HIV HEALTH CARE

• Meta-analysis of EMR-clinical decision support– 12 studies (10 SSA, 2 Carribean)

• Improved ordering rates for CD4• Reductions in data errors, missed appointments• Reduction in missed CD4 results and patient wait time• Increased time spent in direct pt care

– Barriers: technical infrastructure, power cuts, connectivity, computer literacy

– High quality evaluations needed

Oluch, et al., Int J Med Inform, 2012

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PARTNERSHIPS

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HISTORY AND MISSION OF COMMUNITY HEALTH CENTERS

• First funded by the Federal Government as part of the War on Poverty in the mid-1960s.

• Designed to provide accessible, affordable personal health care services for people living in medically underserved communities

• Mission encompasses quality, access, and responsiveness to particular needs of the community served.

• Typical services include primary care (Including Pediatrics, Internal Medicine, OB/GYN, and Family Practice), dental, behavioral health, nutrition, case management and health education.

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HEALTH CENTERS WORKING INDEPENDENTLY

Health Center

Health Center

Health Center

Health Center

Health Center

Health Center

Health Center

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A LEARNING COMMUNITY

Network

Health Center

Health Center

Health Center

Health Center

Health Center

Health Center

Health Center

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CHC HEALTH INFORMATION NETWORKS

• Consortia of multiple health centers supported by HRSA

• Collaborate, share, and/or integrate key functions core operations such as clinical, fiscal, IT, managed care, and administration

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UNIQUE ROLE OF HEALTH CENTER NETWORKS

• Improve health outcomes and support quality care through:– Development and adoption of electronic health record systems – Track quality measurement

• Integrate clinical decision making and performance measures into a commercial EMR

• Research and evaluation

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INTEGRATION OF HIV CARE INTOPRIMARY CARE SETTINGS: LESSONS LEARNED

• Enables health system to test more, initiate more ART, reduce loss-to-follow-up and achieve greater geographic coverage. – Pfeiffer, et al., JAIDS, 2010 (Mozambique)

• May improve treatment outcomes by integrating evidence-based interventions for co-morbid mental health, substance use and neurocognitive disorders.– Eustache, et al., PLOS Medicine, 2013

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HIV MONITORING

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MONITORING (CONTINUED)

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EDUCATION & RETENTION

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IMPLEMENTING PERFORMANCE IMPROVEMENT

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POINT OF CARE REMINDER

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RESULTS

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SHOW PATIENT LIST

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CONTACT PATIENTS

Letter

Email

Phone

SMS/Text

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HCV MODULE DEVELOPMENT

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PROJECT OVERVIEW

• Pilot Program to implement a shared Clinical Decision Support (CDS) Tool at clinics in two US cities (Chicago, IL and Huston, TX) that participate in the Alliance Network/Learning Community

• Focus of CDS was to support both screening and treatment of HCV

• Baseline data compiled related to screening and testing of HCV

• Capture data on use of CDS and impact of screening and treatment post CDS Implementation

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FOCUS GROUP

• Members – clinicians from CHCs with high incidence of people living with HCV

• Models of care – integrated, vertical, referral

• Expense of treatment • Need for policy and funding similar to

RWCA• Need for decision making tools to

support– HCV screening– HCV treatment

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CLINICAL CONTENT DEVELOPMENT PROCESS

• Partnership: IAPAC and The Alliance• Key areas of clinical need identified and prioritized • Subject Matter Experts (SMEs) are assigned to work

with the Alliance Informatics Team to design and build the clinical templates

• Built templates are tested for usability and accuracy • Approves content to put into use based on testing • Alliance Informatics team creates necessary training

material to support use

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Test Sites – Chicago and Houston

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CONTENT ROLLOUT

• Provided access to real-time and recorded webinar style trainings

• Issued a one page FAQ• Offered on-site/live training• Go-live was scheduled for March 1, 2013

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PRELIMINARY RESULTSUSE OF CDS BY SITES BY WEEK

Teter, et al., DDW 2013

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NEXT STEPS:HIV ENGAGEMENT IN CARE

MODULE DEVELOPMENT

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IMPROVING LINKAGE TO TESTING

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§ Entry and retention in HIV care

§ Monitoring ART adherence§ Interventions to improve

ART Adherence§ Adherence tools for

patients§ Education and counseling

interventions§ Health system and service

delivery interventions§ Special populations

Entry/Retention/Adherence Guidelines

Thompson MA, et al., Ann Int Med 2012; 156(11): 817-33 www.iapac.org

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RECOMMENDATIONS:ENTRY INTO/RETENTION IN CARE

§ Systematic monitoring of successful entry into HIV care is recommended for all individuals diagnosed with HIV (II A).

§ Systematic monitoring of retention in HIV care is recommended for all patients (II A).

§ Brief, strengths-based case management for individuals with a new HIV diagnosis is recommended (II B).

§ Intensive outreach for individuals not engaged in medical care within 6 months of a new HIV diagnosis may be considered (III C).

§ Use of peer or paraprofessional patient navigators may be considered (III C).

May 2012 www.iapac.org

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Zuniga and Young, JIAPAC 2013

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SUMMARY

• EHRs can improve health-related outcomes• Development process should engage stakeholders at

all levels• EHR implementation can facilitate CDS use• EHR-CDS modules in development to incorporate

normative guidance for engagement in HIV care

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ACKNOWLEDGMENTS

Alliance•Shannon Pohl•Andrew Hamilton

IAPAC•Vincent Congiu•Imane Sidibé•José Zuniga

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ACKNOWLEDGMENTS

Alliance•Shannon Pohl•Andrew Hamilton

IAPAC•Vincent Congiu•Imane Sidibé•José Zuniga

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Benjamin [email protected]

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