New York Practice Uses EHR Functions for Quality Improvement

Riverdale Family Practice (RFP) is a 48,000-patient family practice located in the Riverdale section of the Bronx, New York. Eight physicians compose the practice, which was founded by Dr. Frank Maselli and Dr. Carl Franzetti 25 years ago. RFP implemented its current electronic health record (EHR), eClinicalWorks, in May 2009 and all patient records have been integrated into the system. The system’s patient portal went live fairly recently and more than 8,000 patients have signed up to use the patient portal.

• The learning curve for effectively using all of the functions of an EHR varies by person.
• The team approach to care is important and is aided by the EHR system by improving communication between providers and staff. The system also assists MAs in performing at the top of their license by following up on alerts and reminders before the provider sees the patient.
• The EHR system helps to improve performance on quality measures for Meaningful Use through clinical decision support systems by providing interventions for needed care. The system’s registry and Meaningful Use dashboard help to track quality measure performance over time.

To encourage interest in Meaningful Use, the practice offered its physicians individual incentive payments for attesting. The practice attested to Meaningful Use in 2011 and also received Level III National Committee for Quality Assurance Patient Centered Medical Home (PCMH) recognition. This PCMH recognition is evidence of the importance that RFP has placed on facilitating partnerships and communication between the practice and its patients and caregivers. The practice is part of the Bronx Independent Practice Association, the St. Joseph Physicians Hospital Organization, and the Montefiore Pioneer accountable care organization (ACO), among other organizations.

RFP first implemented a Pen Chart EHR system 9 years ago. However, after determining that Pen Chart was not robust enough to enable RFP to achieve Meaningful Use and PCMH certification, Dr. Maselli began to research other EHR system options. The practice eventually decided to purchase eClinicalWorks, a vendor recommended and supported by their regional extension center (REC), the New York City Regional Electronic Adoption Center for Health (NYC REACH). Leading up to implementation, all of RFP’s staff attended webinars or in-person training, and eClinicalWorks staff conducted in-office training, which included the use of “dummy” claims and records. Dr. Maselli noted that NYC REACH was an important player in RFP’s EHR implementation and was available to troubleshoot with him during the transition from the previous system to eClinicalWorks. Staff continue to attend EHR training webinars, particularly when there are updates to the system or changes to billing procedures. Catherine Franzetti, RFP’s Office Administrator, noted that the EHR learning curve varied greatly by staff member, and various members of the practice recalled being “wrongly intimidated” by the idea of transitioning to an EHR system or unwilling to let go of their paper-based practices. Dr. Sedlackova recalled that at one point, Dr. Maselli locked her paper prescription pads in a safe so that she would begin to use the EHR’s e-prescribing function.

RFP has identified several ways that it has used the system and its functions to improve the quality of care it delivers to its patients.

Ensuring Continuity of Care - RFP uses an “open access” model, which allows all walk-ins to be seen by an RFP physician. EHR features such as lists of patients’ current medications and medical histories are thus particularly important. These features ensure that, regardless of who provides care to the patient, all physicians in the practice have access to the patient’s history, and any services that were performed or ordered during a walk-in visit are also documented for other RFP physicians who may be treating the patient in future visits. RFP has also established EHR interfaces with three laboratory chains with facilities in the area. Results from these labs are populated automatically into eClinicalWorks for the physicians to review. Additionally, any urinalysis and complete blood count (CBC) testing that is done in-house at RFP is integrated automatically into the patients’ EHRs.

Providing Quality Care - Dr. Maselli recalls that the practice began to realize the need for clinical decision support systems (CDSS) before EHRs were available. In particular, when the practice realized that their pneumonia vaccination rates were very low, they began putting stickers on the charts of patients who had not yet received the pneumonia vaccine but were eligible for it. They saw RFP’s pneumonia vaccination rates increase as a result. With the EHR system, they have been able to expand and improve those efforts by running patient registry reports electronically on a broader range of quality measures to check on which patients are missing flu shots, lab tests, and other types of preventative care.

Today, RFP uses eClinicalWorks’ CDSS function to provide alerts to medical assistants (MAs) regarding services that are needed for particular patients. RFP’s current CDSS is set up to provide alerts for mammograms, colon cancer screening, smoking cessation, alcohol use screening, depression screening, pneumonia vaccination, influenza vaccination, and body mass index (BMI) reminders. Some of the alerts were built in to the system by eClinicalWorks, and the system has also enabled RFP to develop its own customized alerts for its particular patient populations. Once the alerts are included electronically in a patient’s EHR, the MA can then either provide needed care at the time of the visit—such as drawing blood for needed lab tests—or make referrals for more complex care such as colonoscopies. RFP physicians noted that the CDSS is particularly helpful in that it allows the MAs to address many of these alerts before the physicians enter the exam rooms, which enables the physicians to spend more time on other aspects of care. As Dr. Maselli put it, “The EHR helps our focus on a team approach, where the doctors do not have to do everything, and the other staff can do a lot.” Dr. Franzetti noted that while CDSS alerts are good for ensuring that services are provided, it is still incumbent on the provider to ensure that lab values and patient vitals are in control.

Assessing Quality - For each physician, eClinicalWorks’ Meaningful Use dashboard shows the practice’s performance on clinical quality measures necessary for Meaningful Use. RFP also receives periodic quality measure reports from the NYC Department of Health. Dr. Gonzalez noted that RFP’s adult and child immunization rates improved greatly after EHR implementation. Dr. Sedlackova values the ability to see time trends in patient vitals or lab values such as HbA1c over time. In addition, RFP’s patients who have signed up to use the patient portal are able to see their lab results and the time trends on the patient portal. RFP would like to encourage more patients to be that actively involved in their care and plans to increase training for patients to promote more use of the patient portal.

Dr. Maselli and his colleagues are looking forward to greater interoperability between EHRs at different practices and facilities, such as those for specialists and hospitals that are treating the same patient. This will be especially important as the health care system moves toward more coordinated care through new structures such as ACOs. As Dr. Maselli explained, “We’re all speaking English, but some[one] call[s] this a house, another calls it a bungalow, another calls it an apartment complex.” Additionally, Dr. Maselli is looking forward to broader use of health information exchanges (HIEs).

Some early efforts, such as the New York registry of vaccinations, help RFP physicians to see if vaccines have already been provided to patients by other providers. Parents do not always bring their children’s immunization cards with them to RFP, so the registry provides a more reliable way to check on immunizations already received and those still needed. RFP has also joined an ACO sponsored by Montefiore Medical Center that may work toward data exchange among all of the providers involved in the ACO, but that is still under development. The Montefiore ACO also plans to work with the local Regional Health Information Organization (RHIO), which is a developing an HIE.