Bringing High Performing Systems to Small Practices

Despite the evidence base for their role in reducing morbidity and mortality, delivery of clinical preventive services (CPS) has stagnated in the adult primary care setting. In particular, small, independent practices are challenged by the absence of integrated information systems, incorporation of timely and actionable information at the point of care, adequate reimbursement for CPS, shared resources to support technical needs, and quality improvement coaching that is often available in larger integrated care delivery systems. Attempts to boost wide adoption of health information technology (IT) in small practices have been challenging due to costs and lack of technical expertise and support. However, a majority of primary care visits occur in small practices, which highlights the need to understand which systems and resources can be implemented to improve the quality of health care.

This study assessed the effects of supportive electronic health record (EHR) implementation, clinical decision support (CDS) systems, and pay-for-quality programs on the performance of cardiovascular health clinical quality measures (CQM)—aspirin therapy, blood pressure control, cholesterol control, and smoking cessation intervention (ABCS). The project targeted small New York City community providers that had joined the Primary Care Information Project (PCIP), a public health bureau dedicated to integrating health information systems to improve population health. This project also assessed the impact of the interventions on improving the delivery of CPS for the ABCS.

The specific aims of this project were to:

• Determine whether practices that participated in the PCIP program experienced a more rapid rate of improvement on their quality measures than practices that did not participate.
• Determine if PCIP-participating practices are atypical in comparison to other small independent practices in New York City.
• Assess the attributable impact of each intervention: adoption of EHR, CDS, and pilot pay-for quality program.

A mixed-methods approach was utilized across the study aims. Independently owned primary care practices with less than 10 physician staff were recruited for the 2-year pay-for-quality pilot, called Health eHearts. Two cohorts were established from participants of this pilot: early adopters (80) that had implemented the EHR prior to January 2009, and later adopters (60) that had implemented their EHR prior to 2010 but after 2009. All participants adopted the same EHR software.

Practice participants received support and training on using the EHR for tracking and documenting CQM. Practices received quarterly reports on their performance on the ABCS. Half of the practices were randomized to receive incentive payments for achieving patient goals, control of blood pressure, control of cholesterol, or delivering cardiovascular preventive services such as aspirin therapy and smoking cessation intervention.

Early adopters of EHR improved performance on seven of nine CQM in comparison to practices using paper systems, which improved only three of the CQMs. The effect of the CDS tool was mixed. Practice exposure to CDS was not associated with improved performance on ABCS or non-ABCS measures. Receipt of technical assistance was associated with higher performance on quality measures. Financial incentives resulted in modest improvements in cardiovascular processes and outcomes. Contrary to the hypothesis that provider comfort with computers and attitudes (both positive and negative) prior to adoption would predict measures of EHR use after implementation, no significant relationship between attitudes prior to implementation and EHR use were observed. Practices that received financial incentives were more likely to utilize CDS, technical assistance, and review quality reports.

The project team concluded that policymakers who want to accelerate or maximize investments in health IT infrastructure may need to consider payment models coupled with technical support resources to accelerate improvements in areas of preventive care that are underutilized or need improvement.