Overview

Project IMPACT (Implementing Million Hearts for Provider and Community Transformation) examines the effect of a multilevel EHR intervention on hypertension control among patients of New York City primary care practices which serve a predominantly South Asian and immigrant population.

Organization Name

Healthfirst (HF): a not-for-profit health insurance company serving more than 35,000 South Asian members in NYC

Organization Type

• Community outpatient clinic
• Insurance Provider

National/Policy Context

• Hypertension is one of the most significant risk factors for cardiovascular disease (CVD), which is the leading cause of mortality in the United States. 
•  In 2011, the Million Hearts Initiative was launched by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS).
  • This initiative uses team-based approaches, health information technology, and other innovations to reduce the burden of cardiovascular risk factors nationwide.
  • The initiative’s goal is to  eliminate one million heart attacks and strokes every five years.
• These efforts at reducing the burden of CVD and additional national recommendations have underscored the importance of clinical decision support systems to help health care providers when providing patient care.
• However, there remains a gap in interventions targeted to immigrant and minority populations.

Local/Organizational Context

• According to the 2013–2014 NYC Health and Nutrition Examination Survey, South Asian individuals residing in New York City have a significantly higher age-adjusted prevalence of hypertension compared to non-Hispanic white adults (43.0% and 27.5%, respectively). 

• Considering that South Asians and other immigrant populations bear a disproportionate amount of the CVD burden, Project IMPACT implemented a multi-part intervention aimed at mitigating hypertension burden among patients receiving care at NYC primary care practices serving a largely South Asian population.

• Project IMPACT had two components, an EHR-based intervention and a community-health worker coaching intervention. This primer focuses on the EHR-based intervention. 

Patient Population Served and Payor Information

• Patients eligible for the intervention were between the ages of 18 – 85 years, had at least one ICD-confirmed diagnosis of hypertension at a clinic visit, and were not pregnant during the baseline year (12-months before the implementation of the intervention).
• At least 70% of the patient population at each of the primary care practices in the intervention were South Asian.
• 73.4% of patient care revenue came for participating practices came from Medicaid.

Leadership

• Nadia Islam, PhD: Principal Investigator 

Funding

• This study was supported by grant number U48DP005008 from the Centers for Disease Control and Prevention (CDC). 
• The author’s contributions were additionally supported by grant number U58DP005621 from the CDC, P60MD000538, U54MD000538-15, R01DK110048-01A1, UL1TR001445 from the National Institutes of Health (NIH). 

Research + Planning

• A mixed methods baseline assessment was carried out at each of the participating clinical sites to examine their baseline workflow, staff capacity, and EHR-use through ethnographic observation and practice/provider-level surveys. 
• Staff were trained on the EHR-intervention at each of the participating clinical sites.

Tools or Products Developed

• Patient Registry: A feature within the EHR allowing users to query and group patient information based on specified criteria (e.g. diagnoses of particular health conditions, demographic characteristics, etc). 
• Medical Alert: Features built into the EHR to remind staff and health care providers to complete a particular action at the point of care.
• Order sets: Standardized sets of evidence-based treatment guidelines that apply when linked to a medical alert.
• Revised practice workflows: The EHR intervention was tailored to individual practices to ensure that staff could incorporate it into daily workflow without difficulty. 

Training

• Health care providers and staff at the participating clinical sites had a two-day training session focusing on:
  • (1) The generation of hypertension patient registry reports through the EHR
  • (2) The development and implementation of medical alerts and order sets
• The goals of training were to help the clinical teams at each of the sites understand the utility and functionality of the patient registry for follow-up care, to identify patients that have been lost to follow up, to incorporate the patient registries into daily clinical practice, and to monitor to long-term impact of using the patient registry. 

Tech Involved

• Electronic medical record

Team Members Involved

• Administrative Assistant
• MAs
• NPs
• PAs
• Physicians
• Researcher

Workflow Steps

• The EHR intervention was implemented at each clinical site after the clinical team and staff were extensively trained on the use of each of the EHR components. These included:
  • Patient Registry
    • The clinical team used the registry to create reports identifying patients with diagnosed hypertension and poorly controlled blood pressure readings at their last clinic visit to prioritize follow-up visits and keep track of those individuals lost to follow-up. 
  •  Medical alerts
    • The alerts built in to the EHR prompted providers to enter blood pressure readings into standardized fields if they were missing for certain patients, repeat measures for patients with elevated blood pressure readings, and schedule follow-up appointments for hypertensive patients based on how well their blood pressure was controlled. 
  • Order Sets
    • These order sets included prescriptions, lab tests, and counseling orders that were pre-set for patients with hypertension and linked to evidence-based educational materials tailored for the South Asian patient population. 
• In addition, customizable templates were made available to clinical staff to improve the documentation of vital signs and other pertinent health data, and the use of automated appointment reminder texts and letters that can be sent to patients electronically.
• Clinical sites were encouraged to participate in EHR-related incentive programs, such as Meaningful Use (MU) and National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) recognition and collaborate with IPRO, a partner in this intervention.
• After EHR implementation, the clinical sites practices participated in seven on-site technical assistance sessions over the year to troubleshoot ensure the best possible adherence to the intervention protocol. 

Budget Details

The following sources of costs were estimated by the CareZooming team:

• Costs associated with IT staff making adjustments to the EHR systems
• New team members and research personnel located at each of the clinical sites
• Salaries for the Project IMPACT staff involved in training of individuals at each clinical site in using the patient registry
• Time and personnel involved in study enrollment, monitoring, and data analysis 

Where We Are

• Date (Month/Year) Project Described Started: The EHR intervention began in January 2016.
• Date (Month/Year) Paper Published: June 2019
• The intervention period will continue through August 1, 2019.

Outcomes

• Both practice-level and individual level outcomes demonstrated improvements in blood pressure control following the EHR intervention.
• Practice-Level Outcomes: 
  • Proportion of current diagnosed hypertensive patients with a well-controlled BP, defined as <140 mmHg/90 mmHg (or BP <130 mmHg/80 mmHg for patients with diabetes).
    • Relative risk: 1.09; 95% confidence interval (CI): 1.04–1.14 (after adjusting for age and sex)
• Individual-Level Outcomes: 
  • Average systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the last clinic visit among HF-insured patients.
    • Decrease in average SBP: −1.71 (95% CI: −2.88 to −0.54), p=0.004
    • Decrease in average DBP: −1.13 (95% CI: −1.89 to −0.37), p=0.004
  • Odds of current diagnosed hypertensive HF-insured patients with a well-controlled BP, defined as <140/90 (or BP<130/80 for patients with diabetes).
    • Overall treatment odds of blood pressure control: 1.36 (95% CI: 1.08–1.71); p=0.009

Benefits

• An EHR intervention in community-based and primary care settings has the capability to improve hypertension management and control among immigrant and minority populations that are burdened by health disparities, especially the South Asian population.

Unique Challenges

• Some sites might have had difficulty in integrating the EHR intervention components into daily clinical practice, especially after the technical assistance sessions ended. 
• Study limitations include the following:
  • Project IMPACT is a non-randomized trial, which may introduce unmeasured systematic differences and bias study results. 
  • Two different EHRs were used in the trial, which may introduce problems with data collection on the outcomes.
  • Point-of-care medical alerts could be manually bypassed without completing the suggested actions at the clinical sites. 
  • EHR individual-level data on Healthfirst patients were collected on patients meeting eligibility criteria at baseline, and thus patients who changed insurers or were just insured post-2015 were not included in the analysis. 

Personnel Challenges

• Clinical sites reported that time constraints, a high staff turnover, and a large number of part-time staff made it difficult to ensure that all clinical staff were fully trained on all the features of the EHR intervention.

Glossary

• Clinical decision support systems: Computer-based information systems that health care providers can use when implementing clinical guidelines at the point of care. These can be used to assess CVD risk and better individualize the management of CVD and associated risk factors. 

Sources

• This primer was developed by the CareZooming team based on our analysis of a research article found and accessed through public sources. Authors were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• Lopez PM, Divney A, Goldfeld K, Zanowiak J, Gore R, Kumar R, Laughlin P, Sanchez R, Beane S, Trinh-Shevrin C, Thorpe L, Islam N. (2019). Feasibility and Outcomes  of an Electronic Health Record Intervention to Improve Hypertension Management in Immigrant-serving Primary Care Practices. Medical care, 57, S164-S171.
• Lopez PM, Zanowiak J, Goldfeld K, Wyka K, Masoud A, Beane S, Kumar R, Laughlin P, Trinh-Shevrin C, Thorpe L, Islam N. (2017). Protocol for project IMPACT (improving millions hearts for provider and community transformation): a quasi-experimental  evaluation of an integrated electronic health record and community health worker intervention study to improve hypertension management among South Asian patients. BMC health services research. 17(1), 810.
• https://clinicaltrials.gov/ct2/show/NCT03159533