Sunday, November 4, 2007

Community Health Centers in the Service of Public Health

For too many years public health departments and community health centers have lived in their own worlds, with public health focused on geographically and politically designated populations while community health focused on the delivery of primary health care services.

In 2002, when the Institute for Family Health went live with the EPIC electronic health record and practice management system one of our first major projects was to link with the New York City Department of Health and Mental Hygiene to eliminate these silos and to explore the many ways that our work was complementary. What has resulted is a significant array of joint projects that was honored with this year with receipt of the 2007 Davies Award in the category of Public Health from HIMSS. A few of the figures from our application are posted below. We are very committed to using the electronic health record to link our community health center network to the important work of our health department in monitoring and improving the care of all New Yorkers. (You can double-click on any of the figures to enlarge them for easier reading).

Figure 1
The New York City Department of Health and Mental Hygiene collects data from a variety of sources for its Syndromic Surveillance System including ER data, 911 data, absentee data, and pharmacy data. In this figure, the results of their ER data collection are compared to data they receive from our EHR using fever and respiratory symptoms as the trigger. It can be seen that the Institute's EHR data peaks days before the ER data when Flu A is prevalent and is much more responsive than the ER data in showing the less serious flu B outbreak that appears later in the year.

Figure 2
This figure represents the bilateral transfer of information between the NYCDOHMH and the Institute for Family Health. When the NYCDOHMH receives a signal from any source of an outbreak they immediately issue a bulletin via email to all NYC providers. That notice is picked up by our Chief Medical Information Officer and if appropriate an alert is programmed immediately into our EHR. This alert may ask that Insititute providers collect specimens for the DOH for further investigation.

Figure 3
In September of 2007 the DOH reported an outbreak of Legionairres' Disease in the Parkchester neighborhood in the Bronx. Alerts were immediately put in the system such that when a patient presents in either of the two centers we operate in Parkchester, and has a chief complaint of cough the provider receives a message to consider Legionella as a possible diagnosis.

Figure 4
The alert is coupled with a Smart Set of possible notes and orders to facilitate the proper response by the provider

Figure 5
In another shared activity with NYCDOHMH the Institute has begun tracking outcomes on over 40 indicators which are related to the City's "Take Care New York" program. In the example below we track the percent of patients (Men > 35, Women > 45) who have met criteria for cholesterol testing.

Figure 6
In this figure we are tracking the progress that results from an alert to nurses and providers to update the substance abuse history portion of the EHR. One can see that compliance was quite poor to begin with but has steadily increased at all sites.

Additional joint projects include
  • producing a series of algorithms for decision supports that are generic and will be in the public domain and are specific to primary care practice
  • a bilateral interface with the immunization registry
  • automated reporting of communicable diseases
  • development of a "model" EHR for public health

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