July 2009

Grant Results

SUMMARY

From September 2005 to September 2007, the Health Research and Educational Trust partnered with the Alliance of Chicago Community Health Services and the American Medical Association to collect and integrate information on patients' race/ethnicity, primary language and socioeconomic status into an electronic health record system, and to link that information with clinical performance measures.

The goal was to enable the alliance's four community health centers to better target efforts to improve health care quality and to reduce racial and ethnic disparities in care.

Key Results
The project team reported the following results to RWJF as well as in a draft journal article:

  • The project team standardized the recording of information on patients' race/ethnicity, primary language and socioeconomic status, and trained staff at four community health centers to collect that information while registering patients.
  • The project team developed an "interface engine" to transfer demographic information on patients from the health centers and their respective practice management systems to a central electronic health record system, which contained the clinical performance measures.
  • The community health centers began tracking their performance in providing care for asthma, diabetes, high blood pressure and HIV, as well as preventive services, by race/ethnicity and insurance status, individually and across the centers.

Funding
The Robert Wood Johnson Foundation (RWJF) provided a grant of $175,642 to support the project. The Commonwealth Fund also supported the project, with a grant of $150,000.

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THE PROBLEM

Improving the quality of care is one of the primary challenges facing the U.S. health care system. By 2005, evidence showed that efforts to improve quality and reduce racial and ethnic disparities were more effective when informed by demographic data on patients, such as their race, ethnicity and language. (See Unequal Treatment: Confronting Racial and Ethnic Disparities in Medicine, Institute of Medicine, 2003).

Electronic health record systems, which providers use to track and aid clinical care, were seen as a promising tool for improving the quality of care, and for observing and reducing racial and ethnic disparities.

Chicago Network Implements an Electronic Health Record System

In 2000, the Alliance of Chicago Community Health Services—a network of four community health centers serving primarily low-income and uninsured patients—began developing an electronic health record system. (Community health centers are outpatient clinics that receive federal grants.)

The alliance won funding from the Health Resources and Services Administration to implement the system in 2003. In partnership with the American Medical Association (AMA), the alliance also received funding in 2004 from the federal Agency for Healthcare Research and Quality to integrate the AMA-convened Physician Consortium for Performance Improvements nationally recognized clinical performance measures into the system.

Integrating Demographic Data and Performance Measures

The Health Research and Educational Trust in Chicago—the research arm of the American Hospital Association—had developed a method for systematically collecting information on patients' race, ethnicity, primary language and socioeconomic status. The goal of the project, funded by the Commonwealth Fund, was to link patient demographic data, such as race and ethnicity, to clinical performance measures, to pinpoint disparities in processes and outcomes of care and to target quality improvement interventions.

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RWJF STRATEGY

Disparities

When Grant ID# 051071 was issued in 2005, it was under the aegis of RWJF's Disparities team (no longer in operation as of the date of this report). As noted in the 2005 RWJF Annual Report, "[o]ne way to ensure that all Americans have access to quality health care is to eliminate the gaps in care that racial and ethnic minorities experience. In pursuit of that goal, the Disparities team focuses on (1) better understanding of the multiple factors that lead to racial and ethnic health care disparities, and (2) finding practical, effective solutions that will help health care systems improve the quality of care for all patients."

Grant ID# 051071 was an effort to link quality improvement to key demographic data such as race, ethnicity, language, literacy, acculturation and socioeconomic status, in the expectation that it could improve the quality of care for everyone and reduce disparities for the most vulnerable populations. The work conducted under this grant was an exploration of the potential of electronic health records (EHRs) as a potent tool to reduce racial and ethnic care disparities.

Electronic Health Records

In the vision of their supporters, EHRs will provide secure, reliable access to patient health information when and where it is needed to support patient care.

Since around 2000, the Robert Wood Johnson Foundation has supported efforts to expand the use of electronic health records. RWJF's interest in EHRs has been as a tool to improve the quality of care, lower costs and improve consumers' engagement in their health care. As Risa Lavizzo-Mourey, RWJF president, stated in 2004:

Despite all our sophisticated scientific and diagnostic technology, health care doesn't have its own integrated IT system…. Today, our medical and health care information is for others to know and for us to wonder about. 'Knowledge is power' and much of the knowledge about us is kept secret from us. Tomorrow, no more secrets; knowledge will be a power tool that is shared freely. We're finally going to know as much about our health care as the system knows so we'll be able to make informed health care decisions for ourselves and our families.

Thus, RWJF has supported several efforts to develop EHRs, standardize their use and expand their adoption. These efforts have included:

  • Electronic Health Record System Function Model. In 2003, with RWJF grant support, Health Level Seven created an electronic health record system, as well as security standards and communications protocols. Health Level Seven created the Electronic Health Record System Functional Model, and several major industry stakeholders adopted the functional model as a standard for their own companies. (See Grant Results on ID# 049161.)
  • Connecting for Health. In 2004, RWJF joined in co-funding Connecting for Health, an existing initiative begun in 2002 by the Markle Foundation. The initiative laid the groundwork for an effective and secure national health information network that would make patients' medical records available when they are needed, to those authorized to access them. Connecting for Health is a collaboration of representatives from government, health care, industry and consumer groups working to establish policy guidelines and technical solutions to pave the way for nationwide electronic health information exchange. This initiative's overarching goal is a secure environment in which personal medical information is available electronically when and where it is needed by patients and the clinicians who care for them. RWJF's contribution to the effort totaled over $1.5 million between 2004 and 2007. (See Grant Results on ID# 056712.)
  • Institute of Medicine (IOM) Summit. Also in 2004, RWJF co-sponsored a summit of over 200 national and community health leaders convened by the IOM on strategies to improve patient care for five common chronic conditions. The summit's recommendations related to health care communications and technology included the suggestion that federal leadership work to accelerate the adoption of electronic health records. (See Grant Results on ID# 046718.)
  • Surveys of EHR usage. With RWJF support, George Washington University and Massachusetts General Hospital published Health Information Technology in the United States, a survey of how doctors and hospitals are using information systems to drive improvements in quality. The survey estimated that about one quarter of doctors use EHRs to improve how they deliver care to patients. However, fewer than one in 10 are using what experts define as a "fully operational" system. (See news release and report.) A follow-up survey released in 2008 found a 13 percent increase in EHR usage, but no significant association between EHR use and quality of care. (See report.)
  • Personal health records. Project HealthDesign is a $5-million national program designed to support health and information technology pioneers to create a new generation of personal health record (PHR) systems. Project HealthDesign's goal is to design and test a suite of PHR tools and applications that work together to help people achieve their various and specific health goals in an integrated fashion. In this two-phase, 18-month initiative, nine design teams will create personal health applications that address specific health challenges faced by individuals and families. In the subsequent 12-month prototype phase, these personal health applications will be tested in target populations.

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THE PROJECT

The Health Research and Educational Trust, the Alliance of Chicago Community Health Services and the AMA partnered to collect and integrate information on patients' race/ethnicity, primary language and socioeconomic status (household income, number of people and type of insurance) into an electronic health record system, and to link that information with clinical performance measures.

The project's goal was to enable the alliance's four community health centers to improve quality and reduce disparities in care, especially for patients with asthma, diabetes, high blood pressure and HIV. The project also aimed to improve preventive services, such as cervical and breast cancer screenings, immunizations and measurement of blood pressure and cholesterol.

Examples of the performance measures include:

  • Checking the A1C level—which shows average blood sugar control for the past two to three months—of diabetes patients, and ensuring that their blood pressure is less than 130/80.
  • Providing smoking cessation counseling to smokers.

Roles of the Project Partners

The Health Research and Educational Trust oversaw all project-related activities. The trust's team trained staff at the health centers on how to collect demographic data on patients.

The Alliance of Chicago Community Health Services helped integrate the demographic data into the electronic health record system, and linked that information with the clinical performance measures. The AMA developed the performance measures—which won approval from the National Quality Forum—and helped integrate them into the electronic health record system.

How the Technology Worked

Staff at each community health center collected demographic data on patients and entered that information into the site's practice management system: a computer system used to manage the day-to-day operations of a medical practice, including registering patients. Before the project began, each community health center used different race/ethnicity categories, and often collected the information by guessing rather than asking patients.

To standardize collection of demographic data, the project team met with leaders and frontline staff at each site to gain a better understanding of their patient registration process and workflow. Team members developed specific recommendations for improving this process for each site.

The project team then had to develop an "interface engine" to link the demographic data in the practice management system to the alliance's electronic health record system, and then to the clinical performance measures.

Building the interface engine was more time-consuming and expensive than the project team had expected, partly because the four health centers used three different practice management systems. One system was from the same vendor that had created the electronic health record system, but the other two were not. Project staff subcontracted with Orion Health in Santa Monica, Calif., to build the interface engine.

The technology challenges put the project behind schedule. As a result, the health centers were unable to begin using the electronic health record system to target areas for quality improvement until near the end of the project.

Other Challenges

While the electronic health record system could integrate information on patients' race, ethnicity, primary language and socioeconomic status, health clinic staff focused mostly on collecting information on patients' race and ethnicity.

The project team had also planned to develop case studies examining barriers to and opportunities for linking demographic data to electronic health records at community health centers. The team collected information for the case studies during site visits and follow-up telephone calls, but did not write the studies.

Communications

The project team drafted a journal article on the project. Team members also presented information on the project at annual meetings of the American Medical Informatics Association, Center for Health Care Strategies, Institute for Healthcare Improvement and the National Nursing Centers Consortium.

Project staff also gave presentations at a national meeting on patient safety and health information technology, sponsored by the Agency for Healthcare Research and Quality, and at local meetings.

Other Funding

The Commonwealth Fund also supported the project, providing a grant of $150,000.

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RESULTS

The project team reported the following results to RWJF as well as in its draft article:

  • The project team standardized the recording of information on patients' race/ethnicity, primary language and socioeconomic status, and trained staff at four community health centers to collect that information while registering patients.

    The standardized race/ethnicity categories were:
    • Black
    • Asian
    • White
    • Hispanic
    • Native American
    • Unknown.
    The project team reported that staff members were responsive to the training, especially to learning why gathering demographic information on patients was important in measuring health care quality and reducing disparities.
  • The project team developed an interface engine to transfer demographic data from health centers' practice management systems to the alliance's central electronic health record system, which contained the clinical performance measures.
  • The four community health centers collected accurate information on patients' race/ethnicity, and linked that information to clinical performance measures.

    For example, the electronic medical record system showed that the rate of pneumonia vaccination was 64 percent at Center 1 but just 4 percent at Center 4, where the patient population is mainly Black.
  • The community health centers began tracking their performance in providing care for asthma, diabetes, high blood pressure and HIV, as well as preventive services, by race/ethnicity and insurance status, individually and across the centers. Doing so enabled them to see which patients were not receiving the care they needed, target medical interventions to those patients and learn from each other.

    Medical directors and clinical staff at the health centers used the findings to talk with each other about how to improve quality of care. The alliance also shared experiences with the project through organizations such as the National Association of Community Health Centers.

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CONCLUSIONS

The project team reported the following conclusion in the draft article:

  • Other community health centers can use lessons from the project to improve the quality of care and reduce disparities.

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LESSONS LEARNED

  1. Expect community health centers to have difficulty collecting demographic data, and to collect the same types of information differently. The project team had to standardize the collection of demographic data and train staff before transferring the information to the electronic health information system.

    "We believe that this variation is not dissimilar from what we could see in community health centers throughout the country," said Hasnain-Wynia. (Project Director/Hasnain-Wynia)
  2. Before developing a strategy for collecting data, understand an organization's work processes. The project team met with leaders and staff at the health centers to learn about how they registered patients and collected information on them before suggesting needed changes. (Project Director/Hasnain-Wynia)
  3. Foster staff buy-in for changes in work processes by explaining why they are important. Health center staff modified the way they worked because training showed them why collecting demographic data on patients could help the centers measure health care quality and reduce disparities. (Writer)
  4. Expect technical challenges when integrating the electronic systems of different organizations. Because the community health centers used different practice management systems, creating an interface engine to link those systems with the central electronic health record system was difficult.

    "Using electronic health record systems for quality improvement requires much more effort and technical savvy than using it for administrative functions. We didn't take into account all of the steps that need to be done before electronic health record systems can be an effective tool," said Hasnain-Wynia. (Project Director/Hasnain-Wynia)

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AFTER THE GRANT

As of January 2009, the alliance was using the electronic health record system to improve the quality of patient care, and had expanded their focus to include raising quality at partner medical laboratories. The project director planned to write the case studies on the community health centers and an issue brief on the project.

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GRANT DETAILS & CONTACT INFORMATION

Project

Partnership to advance integrating race, ethnicity, and primary language data with national clinical performance measures to improve health care

Grantee

Health Research and Educational Trust (Chicago,  IL)

  • Amount: $ 175,642
    Dates: September 2005 to September 2007
    ID#:  051071

Contact

Romana Hasnain-Wynia, Ph.D.
(312) 503-5509
r-hasnainwynia@northwestern.edu

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Hasnain-Wynia R, Hamilton A, Kaleba E, Kmetik K, Pierce D and Rachman F. "Linking Clinical Performance Measures with Race/Ethnicity Data in Community Health Centers: The Challenge and the Promise of Electronic Health Records." Unpublished.

Presentations and Testimony

"Tapping the Promise of Health Information Technology," at the OMH [Office of Minority Health] Leadership Summit on Eliminating Health Disparities, Washington, January 9–11, 2006 (Plenary Speaker). Available online.

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Report prepared by: Lori De Milto
Reviewed by: Sandra Hackman
Reviewed by: Marian Bass
Program Officer: Chinwe R. Onyekere

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