Although much data in an EHR is generated within a health center’s primary care department, significant amounts of data, such as lab results and specialist reports, are generated outside of primary care. This additional data provides a more comprehensive view of patient’s past services, current health condition, and future needs. Integrating such data can be a challenge for many health centers; a recent HITEQ article discusses behavioral health data utilization and integration within primary care. The usability of integrated data is heavily impacted by the EHR capabilities and configuration. This brief discusses the importance of integrated data, and provides examples of how other health centers have integrated and utilized oral health, colon cancer screening data, and other data within primary care.
The Importance of Integrated Health
According to the Institute of Medicine’s Improving Access to Oral Health Care for Vulnerable and Underserved Populations report, poor oral health is associated with a number of medical conditions including diabetes, cardiovascular disease, and respiratory disease; it may also be associated with inappropriate use of emergency departments. Additionally, significant oral health disparities exist, with dental caries disproportionately affecting racial/ethnic minority groups, rural populations, children, low-income populations, and individuals with special health care needs. HHS developed the Oral Health Strategic Framework 2014–2017 to improve oral health. HRSA focuses on oral health in a number of ways:
· Providing multiple resources dedicated to oral health and primary care integration;
· In 2015, a new UDS Clinical Quality of Care measure was added—Dental Sealants for Children between 6-9 Years; and
· In FY2016, $156 million in grants were awarded to health centers to expand oral health services.
In addition to oral health, cancer screening and chronic care management are important components of primary care. The services that impact these measures are sometimes provided within the health center (e.g. blood pressure measurement, point of care testing, pap smears), while others are usually provided outside of the health center (e.g. mammograms, colonoscopies, diabetic eye exams). To improve the health of patients, health centers must determine how to effectively develop workflows and utilize their EHR to support integrated health data.
Improving Colorectal Cancer Screening Rates
Central City Concern is a nonprofit agency in the Greater Portland Oregon area, serving individuals and families who are impacted by homelessness, poverty, and addiction. Founded in 1979, it has developed a comprehensive continuum of services focused on housing, medical care, and employment and vocational services for the more than 14,000 individuals they serve. They utilize GE’s Centricity as their EHR.
As a multi-service organization, Central City Concern has additional data systems beyond an EHR. For their housing clients, the data is tracked within HUD’s Homeless Management Information System (HMIS). Jeremy Wood came to Central City Concern as their Chief Information Officer in Fall 2015. Under his leadership, Central City Concern has built a data warehouse to synthesize the EHR, HMIS, and other databases, using Microsoft Business Intelligence. In a recent interview, David Caress, Central City Concern’s Director of Quality Management, said “It is much easier now to slice and dice our data as we wish, across programs, by client.”
Each year, Central City Concern picks five clinical indicators to focus on; year to year, some stay on, some rotate off. Colorectal cancer screening has been selected as a clinical indicator for the past few years. In 2014, the proportion of patients who had colorectal cancer screening was 10.65%. Central City Concern has adopted SAMHSA’s approach of Trauma-Informed Care, and uses that lens as they engage their clinical teams. Every two weeks, David and his team review data from the data warehouse, develop talking points, and meet with the clinical teams to share data, talking points, and a “quality thermometer” - a simple graphic to show how close the health center is to meeting its goal for colorectal cancer screening. During these meetings, they also solicit feedback on how they could improve performance. Recently a Health Assistant suggested that they modify the process for collecting Fecal Immunochemical Tests (FITs). Previously a patient would bring the FIT kit back to the health center and the health center would forward the kit to the lab. The Health Assistant suggested changing the process to enter the lab order and print the necessary information so that the patient can send the FIT kit directly to the lab after completion. When the results are completed by the lab, they are sent over to the EHR via an HL7 interface. Central City Concern’s numerous efforts have paid off: The proportion of patients who had colorectal cancer screening tripled from 10.65% in 2014 to 33.87% in 2016.
The South End Community Health Center (SECHC) was founded in 1969 by a group of Puerto Rican mothers who were advocating for access to primary care and partnered with pediatrician Gerald Hass to open a pediatric health center. Dr. Hass cared for patients for 45 years until his retirement in 2014; during his tenure the health center has grown into a comprehensive health center serving 19,000 adults and children; services include dental, behavioral health, and eye care. Over time the neighborhood demographics where SECHC is located have changed. Presently SECHC serves patients of diverse races and ethnicities, although Latino patients remain the majority of those served.
In 2016, SECHC joined a learning collaborative focused on improving colorectal cancer screening sponsored by their Primary Care Association, the Massachusetts League of Community Health Centers. For the learning collaborative, the health center assembled a cross-functional performance improvement team. From 2014-2016, the proportion of patients who had colorectal cancer screening varied from 35.85% to 40.00%, which was below the statewide average of 48%.
SECHC uses Azara Healthcare’s Data Reporting & Visualization System (DRVS), a service that was developed with the Massachusetts League of Community Health Centers. Azara DRVS is a dynamic cloud-based reporting tool that has a number of UDS and other clinical quality measures, with an ability to benchmark against peer health centers, stratify by providers within the health center, and drill down to patient exception lists. Customized data is easy to create. For example, with a few clicks a user is able to identify all health center patients whose latest HbA1c was over 9%, who had not had been seen in primary care in the last six months, and had no diabetic eye exam within the last year. Azara DRVS is updated nightly with the health center’s EHR data.
SECHC had been using GE’s Centricity as its EHR until 2016, and then transitioned to OCHIN Epic. One significant benefit to SECHC using Azara DRVS has been that all historical data from Centricity has been preserved within the Azara DRVS repository and is merged with the current EHR data in OCHIN Epic. This is particularly helpful for clinical quality measures which require a historic lookback, such as colorectal cancer screening.
In a recent interview, Amanda Jusino, South End Community Health Center’s Quality Improvement and Population Health Manager, said that screening patients for colorectal cancer has “many points in that process where hiccups can happen.” The performance improvement team has educated providers, nurses, and medical assistants about FIT, piloted workflow changes, shared provider-specific data generated by Azara DRVS, and utilized Community Health Workers to increase patient engagement.
One area that has been a challenge for many health centers—including SECHC—is closing the referral loop once a patient has been referred for a colonoscopy or sigmoidoscopy. SECHC has had a longstanding relationship with Boston Medical Center, the largest safety net hospital in New England. The hospital and health center are two blocks away from each other, and many health center patients receive their specialty care at Boston Medical Center. The performance improvement team is currently piloting a new initiative where the team utilizes an Azara DRVS report of patients who are overdue for colorectal cancer screening. As Amanda Jusino explains, a staff person uses this report to access the patient in the EHR and then “clicks Epic’s Care Everywhere [which ‘breaks the glass’ with Boston Medical Center] and the staff can see if a patient had a colonoscopy, abstract the whole report into the EHR, and update the EHR health maintenance module with the required information.” Amanda believes that “it will significantly help our data become more accurate… It helps narrow down the list of patients who we actually have to reach out to.”
While their work is continuing, they have showed some good success with all their efforts. The proportion of patients who had colorectal cancer screening hovered between 35% and 40% from 2014 to 2016, and their most recent quarterly data [January through March 2018] was at 57%.
SECHC is considering using Azara DRVS’s Referral Management module, which extracts referral data from the EHR. It consolidates EHR referral data into a spreadsheet format, to quickly see which patients are in each step of the process from initial referral to abstracted results entered into the EHR. A referral coordinator can use this Azara DRVS module to efficiently move patients along in the process; for example, the coordinator could contact a hospital with a list of patients where a referral was initiated, to gather the scheduled procedure date. The coordinator can then ask if another cohort of patients with past scheduled procedure dates actually completed their appointments, and if so, can gather the results of those procedures and abstract them into the EHR.
Improving Oral Health and Primary Care Integration
A health center in Northeastern Massachusetts was seeking to better integrate their primary care and dental departments. The departments were substantially separate, both physically and culturally; there was no communication between the Electronic Dental Record (EDR) and EHR; and their primary care providers did not regularly ask about oral health.
The health center chartered a task force, focused on increasing dental services to their diabetic and obstetrical patients. They encountered early challenges including that many of these patients had an established dental home so weren’t interested in changing to the health center’s dental department. The interest of primary care providers was also difficult to sustain. The task force decided to expand the patient population to include those receiving Medically Assisted Treatment (MAT). Concern existed – many of these patients had distrust in the healthcare system and had heightened concerns about pain and the fear of pain.
As part of MAT services, these health center patients regularly met with a nurse case manager. The nurse case manager was able to gain the trust of these patients, and in doing so could then suggest dental services at the health center. A number of the patients were receptive to the idea. Many had not had regular access to dental care; these additional services also increased the individual patient’s commitment to the MAT program and created more incentive for continued compliance with abstinence. During this time, the health center developed a referral mechanism through the EHR to create a more efficient workflow. Today, many primary care providers routinely ask about oral health, and the health center is averaging 6 referrals a week to their dental program.
Native Health has been working on increasing the connections among primary care, dental care, and behavioral health. The health center was founded in 1978 as a small community nursing program in Phoenix focused on the Native American population. Over time it has grown; today it has a comprehensive set of services at three clinical sites, serving approximately 12,500 patients. Half of the patients are Native American and one quarter are Latino.
Dr. Gautam Aggarwal, Native Health’s Medical Director, shared in a recent interview: “We have a full-time dental hygienist who goes to various outreach events - such as health fairs, elementary schools, and other venues - and she can apply a fluoride varnish to children’s teeth…. As we’ve been engaging in the outreach side, we’re also trying to engage on the clinic side.” Within the health center, they have started to have an interdisciplinary huddle each morning where all providers—medical, dental, and behavioral health—are invited to gather. This practice started a few months ago. Although not every provider participates each day, the interest and participation has grown over time. “We’re really trying to create a bilateral pathway for people to go from one department to another,” Dr. Aggarwal said. For the huddle, the team looks for outstanding labs, imaging, and specialist notes; they also focus on high utilizers and discuss if additional services are needed. As a result of their work, Native Health has seen an increase in oral health screening within primary care. During a pediatric primary care visit, the family is asked if they bring their child to a dentist. If they don’t have a dentist, the team will seek out a dental provider within the health center. If one is available, the dental provider will come to the primary care exam room, introduce themselves to the patient, apply a fluoride varnish and perform a quick dental screening. The dental screening is documented as a dental encounter in the EHR. This process creates “an access point to plug them into care,” according to Dr. Aggarwal.
In July 2017 the health center implemented NextGen; prior to that the EHR and EDR were different systems that did not communicate with each other. “While the EHR itself is cumbersome...” Dr. Aggarwal shares, “having an EHR with one central scheduling system makes [clinical operations] a lot easier.” In the past, providers would have to call other departments to book an available appointment or send the patient to the department. Now, all appointments can be booked through the front desk. Dr. Aggarwal also explains, “The medical providers can see the dental notes and vice versa… but it’s somewhat through a different system in NextGen…
NextGen silos a lot of things.” Although they would like to track internal referrals or other data to show how integration has been increasing, they aren’t currently. The foundational reporting from NextGen has been problematic for them since implementation, and in 2018 they have continued to work to improve the accuracy of the data capture and create more trustworthy reports.
To encourage oral health risk assessments in primary care, the American Academy of Pediatrics has developed a caries risk assessment tool which is also available in Spanish. A portion of the tool is shown below. If a health center would like to institute an oral health screening tool in primary care but is unsure where to start, this tool could be considered.
The National Network for Oral Health Access (NNOHA) promotes more effective oral health within health centers. Their website contains many helpful resources, including some case studies. One such case study was written by Community Healthcare Network, which is comprised of 13 health centers throughout New York City. Community Healthcare Network documented their NNOHA Health Center Oral Health Promising Practice. The promising practice describes how Community Healthcare Network developed eClinicalWorks order sets that are utilized during dental visits, which allow for enhanced data collection and coordination of care with primary care services.
The Role of Health Information Exchanges
As we saw with the example of South End Community Health Center accessing data through Epic Care Everywhere to gather clinical data from Boston Medical Center, the ability to connect to the EHRs of external organizations plays an important role in improving care for patients. The HITEQ Center has a number of resources on Health Information Exchanges (HIEs), including this resource which outlines consideration for participating.
At Native Health, when a patient registers, they sign a consent form that specifies that certain clinical data will be automatically shared with Health Current unless the patient opts out. Health Current is an HIE based in Arizona with clinical data on more than 7 million patients. As an FQHC, Native Health does not have to pay to participate with Health Current, although other institutions pay. Native Health has set an alert within Health Current so that they are notified daily of all health center patients identified as high-risk who have been discharged from an inpatient unit or had an Emergency Department visit. Typically this data is usually within 1-2 days of discharge - dependent on, among other things, the speed with which a hospital finalizes its note and submits to Health Current. This data is pushed to the Nurse Supervisor and Clinical Case Manager. The health center’s visit data is also automatically pushed to Health Current. The only time Native Health needs to initiate an action—to “pull the data”—is when they seek specific data such as specialist reports. Once they find the data, Native Health can then abstract this data into their EHR.
Conclusion
Integrating disparate data sources into a health center’s EHR can seem daunting at times. These examples provide means by which several health centers have overcome specific challenges with integrating both services and key data for supporting care. Given the importance of oral health, behavioral health, and expanded access to services, implementing creative and successful ways of integrating resulting data is an imperative for many health centers and these examples can help define your path for better data integration.