1Primary Care Information Project

Primary Care Information Project

NYC Department of Health & Mental Hygiene

Technology-Driven Intervention to Improve Hypertension Outcomes in Community Health Centers

Divya Suri

August 13, 2014

2Primary Care Information Project

Hypertension

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• Few studies have examined Clinical Decision Support Systems (CDSS)

for hypertension

• There is only one study that had focused on CDSS in Community Health

Centers (CHCs)

• CHCs provide service for more than 15 million Americans, many of

which are at risk for cardiovascular disease

• This study was conducted to compare the impact of a multicomponent

intervention (EMR + CDSS + registry linked performance feedback) vs.

EMR alone on provider adherence to care recommendations and blood

pressure controlled as defined by JNC 7

Why do this study?

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• Quasi-experimental: nonrandomized, pre-post intervention

• Blood pressure measures were collected for each patient encounter for

17 months pre-intervention (June 2007 – October 2008) and 15 months

post-intervention (April 2009 – June 2010)

• The five months not included in the results (November 2008 – March

2009) – intervention adoption period

Study Design: Quasi-Experimental with Repeated Measures

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• Four site federally qualified CHC – Open Door Family Medical Centers –

New York

• Provide primary care to about 40,000 patients per year

• Majority: Hispanic (73.5%)

• Sixty percent of the Hispanic population were foreign born

• Thirty-five percent had Medicaid

• Fifty-eight percent were uninsured

Study Setting and Subjects

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• May 2007 – Open Door installed eClinical Works (eCW) – EMR and

practice management system

• Before intervention, hypertension control was part of the provider monthly

report card. It included 15 quality improvement measures but the

measures were not benchmarked against other providers or a targeted

outcome

• They created longitudinal data from EMRs for all adult nonobstretic

patients with a hypertension diagnosis who had at least once visit during

the study period

Study Setting

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• Exclusion:

• Patients of ethnicities other than black, white, or Hispanic

• Those with more than 30 visits

• Patient visits during adoption period.

• Included: 3,636 patients – 28,263 encounters

Inclusion & Exclusion

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Sample Characteristics

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• Study team

• Open Door leadership, providers, and staff

• Staff from Primary Care Development Corporation – non-profit organization with an

expertise in practice change and improvement

• Created a set of measurable clinical goals related to hypertension management based

on JNC 7

• Goals agreed to by clinic’s Quality Improvement Committee – used as basis for

development of intervention and set of data to extract from EMR

• Part of intervention development – quantitative and qualitative interviews with clinical

staff and leadership – established baseline for evaluating change in attitude and

informed study team about what tools the providers wanted from EMR, training, etc.

Intervention Development

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• CDDS features:

• Alerts – highlighting elevated BP in red

• Template – give provider information to get from patient related to

hypertension and help documentation

• Medication adherence forms – prompt clinical support staff to ask

patients questions about medication adherence

• Order set – focused on hypertension, allowing provider access to a

single screen when ordering these tests or treatments

• Clinical reminders – prompt providers to screen for tobacco use

and/or update indicated tests

Intervention: CDSS

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• Director of Performance Improvement ran quarterly reports on

performance measures consistent with main study outcomes

• Chief Medical Officer presented overall performance of each site vs.

Open Door’s target blood pressure control at regular quarterly staff

meetings

• Provider level performance reports – benchmarked to predetermined

targets – were e-mailed to providers quarterly

Intervention: Individual Performance Feedback

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• Chief Medical Officer conducted two 2-hour training sessions for clinical

staff

• First training: JNC 7 hypertension guidelines, clinical goals and

objectives, and baseline data

• Second training: demonstrate CDSS features and reviewed new

policies and procedure guidelines for hypertension

• Clinical support staff also received 45 minute training customized to their

roles

Intervention: Training

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• Blood pressure control before and after intervention, as defined by JNC 7

Primary Outcome

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Prediction Model for Blood Pressure Control At Any Visit

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Rate of Blood Pressure Control Aggregated Monthly at the Encounter Level