SummaryAs part of a health policy agenda, Take Care New York, the city's Department of Health and Mental Hygiene with support from the mayor initiated the Primary Care Information Project to help primary care practices in medically underserved areas implement and effectively use electronic health records to improve care. Eligible practices receive 2 years of subsidized software fees for an electronic health record that features many disease management and population health functions, initial and ongoing training and support related to implementation and use of the system, and periodic clinical quality reports to support practice-based quality improvement. The program has significantly increased adoption and use of electronic health records by primary care doctors in medically underserved areas and has generated improvements in the quality of care provided to their patients.Moderate: The evidence consists of post-implementation data on the number of practices implementing EHRs as a result of the program and the number qualifying for Federal Meaningful Use incentives, along with pre- and post-implementation comparisons of select clinical process and outcomes measures for patients served by participating practices.
Developing OrganizationsNew York City Department of Health and Mental Hygiene
The Primary Care Information Project is a bureau of the New York City Department of Health and Mental Hygiene's Division of Health Care Access and Improvement.
Date First Implemented2005
The Bureau was established in 2005, and the first primary care practices went live on an electronic health record in late 2007.
Insurance Status > Medicaid; Uninsured; Vulnerable Populations > Urban populations
Physician practices, especially those in medically underserved areas, face multiple barriers to adopting and using electronic health records (EHRs), including financial burdens and a general lack of information technology (IT) resources and expertise, thus preventing them from realizing the benefits that EHR systems can bring. EHRs can be particularly valuable in flagging needed preventive services (a process that is often prohibitively laborious and time-consuming using paper records) and can improve care by making records more legible and accurate, allowing them to be easily shared among providers, and facilitating systematic analysis of medical data to identify opportunities for improvement. Barriers to EHR adoption and effective use in medically underserved areas include the following:
- High costs: EHR systems can require substantial upfront cash outlay [between $15,000 and $70,000 per physician before the American Recovery and Reinvestment Act of 2009 (ARRA)], along with thousands of dollars in ongoing license and maintenance fees.1,2 Although Federal incentive payments authorized by the ARRA cover some of the out-of-pocket costs, practices operating in medically underserved areas still face significant financial barriers to adopting and using EHRs. ARRA incentives are paid primarily after EHRs have been installed and practices use them to fulfill Federal meaningful use requirements. Although practices that qualify can receive up to $21,2503 per eligible provider from the Medicaid program even before meeting meaningful use requirements, this sum is often not sufficient to cover the full out-of-pocket expense. Practices adopting EHRs also must absorb a loss of efficiency and productivity during the transition period, imposing an additional financial burden.4 At the time the Primary Care Information Project was initiated, ARRA incentives were not yet available, and practices were even less able to afford the money and time required to implement an EHR.
- Inadequate technical resources: There are more than 150 products and vendors offering EHR software. Vendors offer a wide array of software functions, some of which are necessary to a practice's operations and some that are add-ons. Additionally, practices often want some ability to customize the software to workflow and needs. Small physician practices typically have no dedicated technical staff to assess and select EHR software, oversee implementation, and provide ongoing support to help integrate the use of technology in medical practice.5
Description of the Innovative ActivityInitially supported by city funding approved by the mayor, the New York City Department of Health and Mental Hygiene (DOHMH) established a new bureau within the Division of Healthcare Access and Improvement called the Primary Care Information Project (PCIP). Funded by public and private sources, it helped primary care practices in medically underserved areas implement and effectively use EHRs to improve care. Eligible practices received 2 years of subsidized EHR software from vendor eClinicalWorks. The version of the software offered to the providers features many disease and population health management functions that were codeveloped by the vendor and PCIP. Practices also received initial and ongoing training and support related to implementation and use of the system; and periodic clinical quality reports to support practice-based quality improvement. Key elements of this policy-based initiative are detailed below:
- Outreach for small practices: PCIP outreach specialists first make contact with small neighborhood practices to educate them about PCIP by answering questions, providing literature and resources, connecting them with other providers already using an EHR, and otherwise encouraging program participation.
- Offers of subsidized EHR software focused on population health: Primary care providers (PCPs) generally qualified for the program if Medicaid beneficiaries and uninsured individuals made up 10 percent or more of their patient population. In addition, select practices in other chronically underserved neighborhoods qualified for additional support to cover hardware, and a waiver of technical assistance fees. For eligible practices, PCIP covered software maintenance and support fees for 2 years. (Practices must pay maintenance fees on their own after this time if they want to keep the software up to date.) The system features a variety of functions to promote chronic disease and population health management, including clinical decision support (e.g., 34 built-in reminders about preventive services for adults), an enhanced patient registry that allows providers to search the records for specific patient characteristics, and electronic prescribing.
- Initial and ongoing training and support: PCIP field staff provided up to 2 years of comprehensive training and implementation support, including teaching practices how to configure and customize the system, maintain privacy and security, and manage and optimize revenue cycles. Once the system was up and running, PCIP provided ongoing technical assistance and support, including helping practices use the system to facilitate quality improvement; identify patients in need of followup; create custom order sets, templates, or alerts; and generate quality reports. Practices paid a one-time fee of $4,000 per provider for training and support.
- Prevention and population health dashboards: Practices that submit preidentified data from their EHR to a central database at PCIP receive a 1-page PDF monthly report that displays 10 clinical quality measures and 10 "use of EHR" indicators with comparison benchmarks/targets, as well as trends from the last 6 months. The provider dashboard allows clinicians to compare their quality measurement trends with an average of other PCIP clinicians and to national targets such as the Centers for Medicare & Medicaid Services Meaningful Use thresholds. A PCIP contact is included in every dashboard, allowing clinicians to ask questions, discuss what is displayed, or request assistance.
- Expansion to other primary care practices and specialists: The physician-assistance framework developed by PCIP formed the basis for the activities of New York City Regional Electronic Adoption Center for Health (NYC REACH), mandated by ARRA to help physicians with EHR adoption. Run by PCIP, it was designated a regional extension center (REC) in 2010 by the Office of the National Coordinator for Health Information Technology. The services of NYC REACH are available to all New York City physicians regardless of patient population. NYC REACH is expanding to other specialties in an effort to help connect care and improve care coordination.
- Support for behavioral health: NYC REACH is also providing subsidized technical assistance and training to behavioral health providers such as psychologists, therapists, and social workers. Assistance is similar to that given to primary care specialists, though the software needs of this population are different and they have expanded software choices.
References/Related ArticlesMore information on the New York Primary Care Information Project is available at: http://www.nyc.gov/html/doh/html/hcp/pcip.shtml.
More information about NYC REACH is available at: http://www.nycreach.org.
Samantaray R, Njoku VU, Brunner JW, et al. Promoting electronic health record adoption among small independent primary care practices. Am J Manag Care. 2011;17(5):353-8. [PubMed]
De Leon SF, Shih S. Tracking the delivery of prevention-oriented care among primary care providers who have adopted electronic health records. J Am Med Inform Assoc. 2011;18 Suppl 1:i91-5. [PubMed]
Mostashari F, Tripathi M, Kendall M. A tale of two large community electronic health record extension projects. Health Aff. 2009;28:345-56. [PubMed]
Shih S, McCullough CM, Wang JJ, et al. Health information systems in small practices. Improving the delivery of clinical preventive services. Am J Prev Med. 2011;41(6):603-9. [PubMed]
Kissam SM, Banger AK, Dimitropoulos LL, et al. Barriers to Meaningful Use in Medicaid: analysis and recommendations. Rockville (MD): Agency for Healthcare Research and Quality. 2012 Aug. AHRQ Publication No. 12-0062-EF.
Contact the InnovatorSarah Shih, MPH
Executive Director of Health Care Quality Information and Evaluation
New York City Department of Health and Mental Hygiene
42-09 28th Street, 12th Floor
Queens, NY 11101
Innovator DisclosuresMs. Shih reported having no financial interests or business/professional affiliations relevant to the work described in this profile, apart from those associated with her employment by the New York City DOHMH.
The program has significantly increased adoption and use of EHRs by primary care doctors in medically underserved areas, and generated improvements in the quality of care for their patients.
Moderate: The evidence consists of post-implementation data on the number of practices implementing EHRs as a result of the program and the number qualifying for Federal Meaningful Use incentives, along with pre- and post-implementation comparisons of select clinical process and outcomes measures for patients served by participating practices.
- Increased adoption and use of EHRs: As of January 2013, PCIP has implemented public health–oriented eClinicalWorks software for more than 3,300 providers in medically underserved areas, who collectively care for 3.5 million patients, making it the largest community-based program to promote EHR implementation in the country. Overall, an estimated 406 percent of physicians in New York City on eClinicalWorks and other EHR systems have received assistance on EHR adoption and meaningful use from NYC REACH. As of April 30, 2013, 6,383 eligible providers in New York City, on eClinicalWorks and on other EHR systems, have received assistance on EHR adoption and meaningful use from NYC REACH. In addition, providers participating in Meaningful Use incentive programs in New York City have received incentives of $365 million.
- Better care: Participating practices have improved the care provided to patients in a number of areas targeted by the program. For example, in PCIP practices submitting data for analysis, the proportion of hypertensive patients with their blood pressure under control rose from 46.0 percent to 54.8 percent, with more than one-half of participating practices seeing improvements in this area.6 More than one-half of practices have also improved the provision of care regarding breast cancer screening for eligible women, hemoglobin A1c testing for those with diabetes (with an average increase of five percentage points), and the recording of body mass index for all patients. Furthermore, an independent study compared performance on several quality measures with the practices' receipt of technical assistance, illustrating that practices utilizing more technical assistance were more likely to improve their performance than those using little or no technical assistance.5
Context of the InnovationThe DOHMH protects and promotes the health and mental well-being of city residents, including providing mental health and developmental disability services, as well as chemical dependency prevention and treatment. As part of a health policy agenda called Take Care New York, DOHMH established multiple programs to target "winnable battles" and articulated actions for consumers, clinicians, and the community to help prevent and control the top 10 causes of death and illness in the city (e.g., tobacco-related illnesses; cancer; and chronic diseases such as asthma, diabetes, and heart disease). The city’s mayor is an active champion to improve the health of city residents. Dr. Thomas Frieden, former health commissioner and current director of the Centers for Disease Control and Prevention, along with Dr. Farzad Mostashari, the founder and the first Assistant Commissioner of PCIP, and later National Coordinator for Health Information Technology, articulated the initial framework for integrating health IT, primary care, and public health. Substantial political support from the mayor, Michael Bloomberg, and the state’s health commissioner, Dr. Richard F. Daines, made possible significant capital investments by the city and state for health IT.
Planning and Development Process
Key steps included the following:
- Securing initial public funding: The Office of the Mayor set aside tax levies of $25 million to establish PCIP and subsidized the cost of EHRs for safety-net clinicians. The City Council subsequently authorized an additional $2 million for hardware purchases and Internet connectivity.
- Establishing a bureau: NYC DOHMH established a new bureau under the Division of Healthcare Access and Improvement. Dr. Mostashari was appointed the Assistant Commissioner of PCIP and hired staff to implement the programs.
- Soliciting outside funding: In addition to initial funding from the city, Dr. Mostashari and staff generated applications to various grants and foundations to supplement the city’s investment.
- Choosing and modifying EHR system: PCIP evaluated more than 25 EHR systems as part of a competitive procurement process and selected eClinicalWorks. PCIP then collaborated with the vendor to develop a version of the system to incorporate prevention-oriented features in alignment with the Take Care New York goals (see the bullet below for more details).
- Coordinating with other public health efforts: Established in 2004, Take Care New York monitors 10 priority health areas that present the largest opportunity to reduce disease burden and improve health among New Yorkers. Target areas include cardiovascular health (with a core set of measures designated as the highest priority for improvement), diabetes, asthma, smoking cessation, HIV testing and treatment, cancer screening, immunizations, establishing a regular health provider, and screening and treatment of depression as well as alcohol and substance abuse. PCIP used these areas to select and develop clinical quality measures to be embedded in the EHR system.
- Dovetailing with State funding: In 2007, New York state passed the Health Efficiency Affordability Law, which provided capital investment for health IT. This includes purchase of hardware, software, and technical assistance in multiple practice settings, such as federally qualified health centers, small neighborhood practices, and behavioral health organizations. The legislation also provided funding for care coordination around chronic conditions and for integrating health information exchange across care settings.
- Reaching out to primary care clinicians: The outreach team contacted primary care providers in small practices, federally qualified health centers, and hospital-owned ambulatory clinics to offer the subsidized EHR software. The team worked with medical societies in each borough and other medical leaders in the community to identify and approach practices that could benefit from the program. PCIP used educational programs, software demonstrations, and e-mails containing program literature to generate interest.
- Using contacts relationship management software: PCIP purchased licenses from Salesforce.com, a Web-based software application, to log its communications with practices, thus allowing staff to assess its efforts, identify practices in need of followup support, and better coordinate communications to avoid overlapping contact or conflicting messages.
- Scaling assistance to priority primary care providers for meaningful use: Through PCIP's original program definition (e.g., serves at least 10 percent Medicaid or uninsured patients), more than 3,000 providers agreed to adopt EHRs. ARRA authorized funds to reward Meaningful Use of EHRs to primary care providers as well as create regional extension centers to assist PCPs in the adoption and meaningful use of EHRs. PCIP applied to become an REC and established NYC REACH. Services by NYC REACH were expanded to assist providers to enroll in the Meaningful Use program and work towards achieving Stage 1 Meaningful Use.
Resources Used and Skills Needed
- Staffing: PCIP has more than 100 employees, including the assistant commissioner (who leads the bureau), an administration and community engagement team of 12, a program evaluation and planning team of 13, and a technology development team of 23. The largest group, of approximately 70, carries out the activities for NYC REACH.
- Costs: The annual costs of PCIP range between $6 million and $7 million, depending on staffing levels at the bureau. Other nonpersonnel costs include space, computing equipment, software license fees, and cellular telephone plans.
Funding SourcesAgency for Healthcare Research and Quality; Centers for Disease Control and Prevention; Office of the National Coordinator for Health Information Technology; New York City Department of Health and Mental Hygiene; Robin Hood Foundation; WellPoint Foundation; Emblem Health Plan; New York State Health Efficiency and Affordability Law; New York City Tax Levy
In addition to the listed funding sources, PCIP collected a one-time $4,000 fee for each full-time equivalent provider who enrolled in the program before the availability of ARRA/REC funding.
Tools and Other ResourcesThe provider dashboard is available at: http://www.nycreach.org/reach_wiki/index.php/Main_Page.
Getting Started with This Innovation
- Be imaginative in hiring: Some of the most effective staff at PCIP tend to be generalists who are willing to work around challenges, rather than experts in a particular area.
- Involve all practice personnel in EHR projects: Administrative as well as clinical staff have important rolls to play in EHR use, and often are the key decisionmakers. In small practices, the involvement of office managers may result in a higher likelihood of enrollment.
- Emphasize potential benefit on workload: Clinicians should understand that EHRs will eventually make their work day easier. Clinicians will not adopt an EHR based solely on its potential to improve population health if they believe the systems will impose additional burdens, either on themselves or their staff.
- Be persistent: More than three-quarters of practices did not agree to participate until they had 10 or more contacts from PCIP staff. Most practices received between 10 and 20 contacts, and some needed 30 to 40 before they agreed to participate.
- Offer deadlines, limits, and feedback: Clinicians responded best when PCIP staff presented them with target dates, stressed that the available number of free software licenses was limited, and kept them informed on the progress of their application.
- Train outreach and support staff: Clinicians generally did not know what to expect or how to anticipate the requirements associated with adopting an EHR. In fact, the PCIP outreach team spent most of its time answering questions about startup costs and the impact of the system on practice resources. To respond effectively, they had to know how much money practices should set aside for hardware, monthly Internet access fees, hiring an IT consultant to assist in setup, and other potential expenses, as well as how much time to set aside before and during the installation. Inperson software demonstrations also helped, as did connecting clinicians to other clinicians already using an EHR.
- Emphasize upfront funding: Clinicians often understood the benefits of EHR adoption, but still refused to consider adoption in the absence of immediate and substantial financial assistance. Rebates and partial upfront subsidies tended to be less effective in convincing providers, as funding seemed insufficient or too remote.
- Leverage relationships: PCIP worked with physician membership organizations and health plans to build relationships with individual clinicians, including having the leaders of these organizations send letters about the program, copresent enrollment materials, or repeat messages about PCIP in their routine communications.7
Sustaining This Innovation
- Be prepared for turnover: PCIP employees are attractive job candidates for a variety of health IT positions due to the depth and breadth of their knowledge about EHR implementation. Consequently, they often get hired away, making it important to have an active, ongoing recruiting effort to replace those who leave.
- Use customer relationship management tool: As noted, PCIP used a vendor to log communications with practices, thus allowing staff to better manage its communications with and support of participating practices.
- Expand targeted provider base to include behavioral health and specialty practitioners: Funding from grants beyond primary care can attract a wider range of clinicians, eventually enabling universal health information exchange.
- Engage payers: Clinicians are much more likely to be engaged in using EHRs to improve chronic care and population health if payers align reimbursement models or provide financial incentives for doing so.7
Use By Other OrganizationsMuch of the philosophy behind current Federal health IT policy is based on PCIP. For example, the Medicare and Medicaid EHR Incentive Programs incorporate technical and financial support for FQHCs and other practices caring for a large number of Medicaid beneficiaries and uninsured individuals, and also focus on helping practices improve preventive and chronic care.
Fleming NS, Culler SD, McCorkle R, et al. The financial and nonfinancial costs of implementing electronic health records in primary care practices. Health Aff. 2011;30(3):481-9. [PubMed]
Shih SC, McCullough CM, Wang JJ, et al. Health information systems in
small practices. Improving the delivery of clinical preventive services.
Am J Prev Med. 2011;41(6):603-9. [PubMed]
Ryan AM, Bishop TF, Shih S, et al. Small physician practices in New York
needed sustained help to realize gains in quality from use of
electronic health records. Health Aff (Millwood). 2013;32(1):53-62. [PubMed]
Samantaray R, Njoku VO, Brunner JW, et al. Promoting electronic health record adoption among small independent primary care practices. Am J Manag Care. 2011;17(5):353-8. [PubMed]
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Original publication: August 28, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.