Article Figures & Data
Figures
- Figure 1.
The “Healthier Together” Project County Partnership. CHIO, County Health Improvement Organization; HIE, Health Information Exchange; PCP, Primary Care Physician/Provider; PEA, Practice Enhancement Assistant; PSRS, Preventive Services Reminder System; Pts, Patients; WC, Wellness Coordinator.
Tables
- Table 1.
Demographics of the Patient Population Reached by Oklahoma County Wellness Coordinators During the Intervention Period
Demographic Parameter Outreach Effort Outcome County Population Reference Number of Individuals 9,138 ∼15,000 Age (years), mean (SD) 38 (21) Mean: 38 Sex (female) 50.5% 52.1% Race/ethnicity Insufficient data available in health records 84% White 12.4% Hispanic/Latino Spatial distribution of population (by town) Town A 62% 30% Town B 8% 15% Town C 7% 3% Median household income Data not available in health records $37,000 - Table 2.
Rates of Delivering Preventive Services Before and After Outreach Program Implementation, Grouped by Service Type and Care Delivery Domain
Preventive Service Type Baseline Service Rate* Intervention Service Rate* P Share of Total ROI† Primary care practice domain Smoking cessation counseling 33% 71% <.01 14% Adult immunizations (influenza and pneumococcal vaccine) 63% 78% <.05 3% Diabetes management (diabetes checkup visits & HbA1c measurement) 48% 75% <.01 18% Well child visits 51% 60% <.05 13% Physical activity counseling 27% 38% <.01 14% All practice-based services 44% 64% <.01 62% County hospital and health system domain Colonoscopy (referred) 38% 43% .07‡ 31% Mammography (referred) 55% 63% <.05 6% Bone density screening (referred) 24% 30% <.05 1% All referred services 39% 45% .05 38% County healthcare domain All services combined 42% 57% <.01 100% ↵* Service rates were measured by combining HIE record analyses and medical record abstractions. HIE records and health system-level service reports were essential to estimate the rate of referred services (mammography, colonoscopy, and bone density screening).
↵† Total ROI includes all returns generated across the project, including all organizations and services.
↵‡ Although this trend did not reach statistical significance across the county, there was an increase in the absolute number of colonoscopies that were referred to the health system that employed the wellness coordinator during the intervention period compared to the baseline period. Most of these patients received a call from the wellness coordinator.
- Table 3.
Types, Frequency and Consequences of Problems with the Availability or Quality of Health Information and Solutions Implemented in the Healthier Together Pilot Study
HIE Data Quality Problem Type Frequency of Data Quality Problem in HIE Records Consequences of Data Quality Problem & ▸Mitigation Strategies Patient is not attributed to a PCP (no PCP listed) Decreased from 94% to 80% over the pilot Services & quality metrics can't be linked to PCP ▸Additional patient matching using EHR data Low actionable* data contribution from PCPs Decreased from 89% to 66% over the pilot Less information on PCP services ▸ Improving data interfaces & manual extractions from EHRs Missing or wrong patient phone numbers Decreased from 49% to 38% over the pilot Patient reach barriers ▸ Better documentation & additional data extraction from billing records Risk factor rate lower or higher than expected† Smoker (5% vs. 16%‡) Inaccurate care gap predictions ▸ Better chart documentation and calibrating data interfaces Diabetic (21% vs. 10%‡) Preventive service rates are lower than expected† Mammography (5% vs. 11%‡; increased to 13% over time) Inaccurate care gap predictions ▸ Better chart documentation and calibrating data interfaces Race or ethnicity information not available About 98% to 99% of records (remained unchanged) Less tailored care recommendations ▸ Improve documentation of race in patient chart Skewed data contribution among organizations 30% of HIE records are over-concentrated in SE of county Some organizations dominate as data source ▸ Oversample records in northern county region EHR, Electronic Health Record; HIE, Health Information Exchange (patient records aggregated regionally); PCP, primary care practice.
↵* Actionable data include health risk factors (e.g., smoking status), reports, and laboratory findings pertinent to prevention, and history of preventive services. Low-value data include administrative visit information and free text notes that often “bloat” interoperable records causing excessive transmission and processing times.
↵† Rate means the frequency of the occurrence of health risk factors or preventive services in HIE datasets relative to the known prevalence of these factors in the population.
↵‡ State of the State's Health Report 2014, Oklahoma State Department of Health.
