Improving Patient Health Outcomes at Primary Care Systems in Clay, WV Using an Electronic Health Management System

Version 2.0: 2/11/2008 Prepared by: Sarah Chouinard, MD. and Jack L. Shaffer, Jr.

IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHR

Case Study for Primary Care Systems
Improving Patient Care Using an EHR Background
A number of studies strongly suggest that health care services delivered in the United States often do not meet patient needs. One of these studies indicates that only 50 percent of the individuals studied received recommended preventive care and only 60 percent received recommended chronic care. Equally troubling was the finding that, of those studied, twenty percent 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 received only about half (54.9 percent) of recommended medical care in compliance with evidenced-based guidelines. This study added to the mounting evidence of deficiencies in the U.S. health care system, which was highlighted in a 2001 Institute of Medicine report, “Crossing the Quality Chasm”, documenting the chasm between the care Americans receive and the care Americans should expect. There is emerging evidence that electronic health information systems (referred to generically herein as “EHR” for “Electronic Health Record”) can have a profound impact on quality of service and patient outcomes if implemented in concert with recommended health improvement processes. The use of EHR systems permits participants to measure and report externally on a number of quality indicators and more importantly, to use these results internally to continually improve 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 in real-time rather than a retrospective environment, facilitating continuous improvement of the workflow and processes of clinical activities. It also facilitates communication and coordination of care 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 the chronic 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 by community health centers through the Health Disparities Collaborative efforts coordinated by HRSA, see: http://www.improvingchroniccare.org/) is improving the health outcomes for patients of Primary Care Systems in the rural community of Clay, West Virginia.

Primary Care Systems
Primary Care Systems, Inc., is a Federally Qualified community health center (FQHC) serving the residents of Clay County, West Virginia, and surrounding areas. Primary Care Systems has two primary clinical locations in Clay and Big Otter within Clay County, and three school-based health centers at Clay Elementary, Clay Middle and Clay High Schools (with a fourth center planned for the new Big Otter Elementary School in 2008). Primary Care Systems serves approximately 7,200 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 Primary Care Systems currently includes 4 FTE physicians and 4 FTE mid-levels providing a range of primary care services, including laboratory, radiology, behavioral health and maternity and wellchild services.

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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 the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services and the Center for Medicare and Medicaid Services (CMS) that is assigned to private non-profit or public health care organizations that serve predominantly uninsured or medically underserved populations. FQHCs are located in or serve a Federally-designated Medically Underserved Area/Population (MUA or MUP). FQHCs must operate under a consumer Board of Directors governance structure, and provide comprehensive primary health, oral, and mental health/substance abuse services to persons in all stages of the life cycle. FQHCs provide their services to all persons regardless of ability to pay, and charge for services on a Board approved sliding-fee scale that is based on patients’ family income and size. FQHCs must comply with Section 330 (of the Public Health Service Act) program expectations/requirements and all applicable federal and state regulations. FQHCs are also called Community/Migrant Health Centers (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 a member of the Community Health Network of West Virginia (the “Network’) and as a pilot site to test concepts of personal health management and care coordination for the West Virginia Medicaid program. This preparation involved implementation of the Care Model clinical processes and realignment of clinicians within care teams. Care managers and coordinators were 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 the configuration of the electronic health information system clinical reminders, health factor reports and patient education material. In 2006, Primary Care Systems began implementation of an electronic health management system, starting with care managers and clinical support team members and then expanding to physicians. One of the aspects of the project that makes Primary Care Systems truly unique is that it is the first community health center organization in the country to successfully implement an adapted version of the Resource and Patient Management System (“RPMS”) clinical information system developed and used by Indian Health Service. 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 (a software platform that is largely in the public domain with a limited number of modules that are proprietary) that has been used by the Indian Health Service to dramatically improve health outcomes for tribal populations in a number of ambulatory care settings. MedLynks has templates and tools adapted for use in community health centers and can serve as an alternative to commercial applications to rapidly accelerate the adoption of population-based, patientcentered electronic health information technology.

Clinical Outcome Measures
Primary Care System, like most FQHC grant recipients, is required to undergo periodic Office of Performance 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 requires that an FQHC select at least two quality measures from a list of fourteen possible measures and perform a data analysis on those measures for the last three years. To prepare for its periodic OPR evaluation, Primary Care Systems selected two measurements to analyze over the past three 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.
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IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHR

These 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 patient outcomes for diabetics and to assure that children and adolescents with obesity received appropriate weight management counseling.

Impact on Provider Productivity
In preparation for the OPR review, Primary Care Systems was required to produce the last three years of metrics on both selected measures. In the production of these metrics, the clinical team noted significant differences in the results during the period from 2005 to 2007. A careful analysis of the data and clinical process changes suggested several factors influencing the favorable trends in these outcomes. The clinic characterized 2005 as a “normal” baseline year for them. During this period, Primary Care Systems had a consistent number of providers; they were using paper charts, and were operating primarily as they had in the past as the clinical team started to evaluate the impact implementation of the Care Model would have on clinical practices. In 2006, two disruptive events occurred within Primary Care Systems: 1) – The clinic lost two physicians, and 2) – the clinicians began to implement MedLynks. With the loss of two physicians, 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 in productivity due to the learning curve required to integrate the EHR into the patient treatment process. Interestingly enough, studies tend to show that if a clinic or health center is not operating properly, the health outcomes of chronically-ill patients do not improve and may even decline. As Dr. Sarah Chouinard - the Medical Director of Primary Care Systems noted, “if you have an unhealthy clinic, you will have unhealthy patients.” In 2007, Primary Care Systems returned to a “normal” level of productivity. The clinic replaced the 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 tool since it is based upon an actual blood test. It is not a “soft measure” like counseling where the meaning 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 test results.

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IMPROVING PATIENT CARE AT CLAY PRIMARY CARE CENTER USING AN EHR

Diabetes HgBA1c
90.00% 80.00% 70.00% 60.00% 50.00% 40.00%
Count: 98 Count: 86

After EHR Implementation

79.30% 68.50% 59.30%
Count: 149

40.70%

31.50%
30.00%

20.70%
20.00% 10.00% 0.00%
Count: 45 Count: 59 Count: 39

2005
HGBA1C<7.0 Percentage

2006

2007
Uncontrolled Percentage

In evaluating this specific measure, the 2005 number of 68.5% of the diabetic population of Primary 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 is somewhat higher at around 70%. For 2006, the lower numbers can be attributed to the disruptions mentioned above that were occurring at the clinic. In 2007, Primary Care System achieved an increase to nearly 80% in the number of patients whose diabetic condition was controlled. The number of diabetic patients being evaluated also increased by 33% from 2005 to 2007. The patient population base increase was directly attributable to the use of the EHR in more uniformly capturing these diabetic patients for care management. The improvement in outcomes from 2006 to 2007 is directly related to the use of information from the EHR and the implementation of the care model. In evaluating these outcomes, Dr. Chouinard commented, “These increases are not because we suddenly got smarter or practiced medicine in a different way – it’s not like we all of sudden learned how to use insulin. The increase was due to 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 recent HgBA1c test. Without an EHR, tracking this information is difficult. This type of tracking in a paper-based chart system requires using reports from a practice management or registry system based upon ICD or CPT codes (that tend to reflect visit purpose more than overall prevalence of chronic conditions and then having a staff member laboriously perform chart audits for the specific lab. With the EHR, the clinic captures all meaningful patient clinical information, not just a 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 goals for diet and exercise, two important elements of therapeutic lifestyle change this have proven vital in achieving and sustaining good control of blood sugar levels for diabetic patients.

Obese children and adolescents ages 2 – 19 referred to counseling
Another persuasive outcome improvement attributable to use of the EHR by Primary Care Systems was the increase in the number 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.
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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 44.4%

2005
YES COUNT NO COUNT

10 55.6%

2 8.0%

2006
YES COUNT NO COUNT

23 92.0%

After EHR Implementation

156 100%

2007
YES COUNT NO COUNT

0 0%

In 2005, Primary Care Systems only captured the BMI statistic on 18 patients that were children or adolescents that met the targeted class (i.e., obese). Of those 18 patients, only 8 were referred to weight management counseling. In 2006, the overall capture rate of BMI metrics increased slightly, however, the referrals decreased to 8%. This percentage indicates that only 2 of the 25 obese adolescents or children identified in 2006 were referred to counseling. Upon analyzing the reason for this decline between 2005 and 2006, it was discovered that much of the decline could be attributed to the loss of one specific provider who practiced at one of the school based centers with a particular interest in childhood and adolescent obesity. In 2007, the numbers increased dramatically. The entire population in this category increased nearly 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 – can be 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 calculation to determine and record a patient’s BMI. With the adoption of the EHR, the BMI on each patient is calculated and stored automatically with every visit – it is not an extra step for someone to perform. Once the data was captured within the EHR, it was a simple procedure to produce reports showing the patients that fell into the specific categories and to use these reports for follow up and referral to counseling. The EHR also allowed for the creation of clinical reminders to aid the nurse or clinical coordinator to recommend counseling to these patients at the time of care, during the patient visit rather than retrospectively based upon chart audits (as was the case pre-EHR implementation). The improvement reflected in this measure demonstrates how an EHR can aid in the quality improvement process by helping to establish a standard of consistent care throughout an

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organization. Without an EHR, these evidenced-based best practices are often only consistently employed by specific providers with a particular passion for the issue or targeted condition.

EHR as a tool in a process
One inference that can be drawn from these outcome results is that improvements were not occurring because the patients just weren’t coming to the clinic. The clinic would perform an HgBA1c test on the patient and then perhaps would not see the patient again for a year (or more). This was largely due to the reactive nature of most health care engagements and the acute care nature of most health care delivery. Most encounters in the old delivery system of Primary Care Systems, like much of primary care in general, was based upon a patient-initiated interaction with a specific emergent condition necessitating care, relegating many unmet needs to a “get to it when we can” approach based upon 15 to 20 minute clinical increments with physicians or mid-level providers. One of the enormous benefits of a population-based EHR is identifying those patients who are not up-to-date on recommended or required care. The EHR allows the clinical care teams to be proactive in engaging patients in preventive and chronic disease self management. As noted above, this requires a two-fold approach utilizing care management teams empowered and informed with health information from the EHR. In the HgBA1c improvement process, Primary Care Systems generated periodic reports of patients who had an HgBA1c or other diabetic-type lab result at anytime in the clinic. Once a patient was on this list, the care teams began to contact those patients by generating letters and making phone calls over several months. During the first month a person was listed on the report, 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 letter asking that they schedule a visit. If a patient remained on the list after sixty days, they received a phone call from the clinical coordinator. After ninety days, the attending doctor called the patient requesting a follow-up visit. The process would have been too cumbersome prior to implementation of MedLynks, because these lists had to be generated manually. Primary Care Systems also implemented processes and work flow changes to bring negative health 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 health concern that triggered the visit). With the EHR and the clinical reminders integrated into MedLynks, the triage nurses and care managers of Primary Care Systems could bring negative health factors such as an adverse BMI (indicating obesity or an overweight condition) to the attention of the patient. The experience at Primary Care Systems confirms studies that have found that repeatedly addressing these chronic conditions during clinical encounters can empower and motivate a patient to take charge of his or her health and make necessary lifestyle changes. Another example of the power of these clinical reminders in improving health outcomes is in the area of tobacco cessation. Prior to implementation of the EHR, the rate of documented counseling 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 counseling for tobacco cessation of one hundred percent. The impact that these changes have on the individual lives of the patients is best exemplified by a patient that had been a lifetime smoker, but recently was successful in her quest to kick the habit through counseling and patient selfmanagement guided by the reminder system and the work of a dedicated care manager. What were occasional successes, like that of the patient described above, now are more commonplace through the use of MedLynks. It is said that information is power and applied clinical information at the point of care is a powerful force for health improvement.

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Next steps: Future Improvements
Now that Primary Care Systems is making significant progress in the delivery of quality health care, 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 persistent asthma that are not using appropriate medications, such as an inhaled steroid. Having adolescent asthmatic patients who need controlling medications on a steroid has been clinically proven to save lives and the physicians at Primary Care Systems believe that they can dramatically improve upon their outcomes in this category in much the same way they have in the aforementioned measures. They also plan on developing reports and metrics for all other standard nationally-recognized clinical outcome measures. Dr. Chouinard has summarized the commitment of the clinical staff at Primary Care Systems this way: “The more we can measure and evaluate, the more we can improve the care for our patients. As we master the use of this system, we are excited about the level of improvement we can achieve for our patients with these tools as we move forward.”

Summary
It is important to recognize that an EHR is only one component in the health improvement process. This case study shows that an EHR is a tool that can produce dramatic health improvements if properly applied. In this case study, the particular tool had clinical reminders and a number of other care management applications integrated to enable the care teams at Primary Care Systems to deliver better health care; however, much of the health improvement was achieved 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 substantially better outcomes. As shown by this case study, Primary Care Systems is making significant strides in improving the quality of the care it is delivering to its patients through the effective use of an EHR and the adoption of the clinical care model. Although the implementation of either singularly could have some impact on improved health outcomes, the most significant gains are made when the care process realignment and the information and management tools are integrated and implemented together.

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