Daren Anderson

Using electronic health records data to identify patients with chronic pain in a primary care setting

OBJECTIVE To develop and validate an accurate method to identify patients with chronic pain using electronic health records (EHR) data at a multisite community health center. MATERIALS AND METHODS We identified patients with chronic pain in our EHR system using readily available data elements pertaining to pain: diagnostic codes (International Classification of Disease, revision 9; ICD-9), patient-reported pain scores, and opioid prescription medications. Medical chart reviews were used to evaluate the accuracy of these data elements in all of their combinations. We developed an algorithm to identify chronic pain patients more accurately based on these evaluations. The algorithms results were validated for accuracy by comparing them with the documentation of chronic pain by the patients treating clinician in 381 random patient charts. RESULTS The new algorithm, which combines pain scores, prescription medications, and ICD-9 codes, has a sensitivity and specificity of 84.8% and 97.7%, respectively. The algorithm was more accurate (95.0%) than pain scores (88.7%) or ICD-9 codes (93.2%) alone. The receiver operating characteristic was 0.981. DISCUSSION A straightforward method for identifying chronic pain patients solely using structured electronic data does not exist because individual data elements, such as pain scores or ICD-9 codes, are not sufficiently accurate. We developed and validated an algorithm that uses a combination of elements to identify chronic pain patients accurately. CONCLUSIONS We derived a useful method that combines readily available elements from an EHR to identify chronic pain with high accuracy. This method should prove useful to those interested in identifying chronic pain patients in large datasets for research, evaluation or quality improvement purposes.

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial.

PURPOSE Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care. METHODS Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age. RESULTS Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group. CONCLUSION E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.

Self-Management Goal Setting in a Community Health Center: The Impact of Goal Attainment on Diabetes Outcomes

Abstract Objective. This study sought to evaluate the details of self-management goal setting in a largely Hispanic population of patients with type 2 diabetes, to evaluate the impact of various factors on goal attainment and to assess the impact of self-management on glycemic control. Setting. The intervention was conducted at Community Health Center, Inc., a large, multisite federally qualified health center in Connecticut caring for an ethnically and racially diverse population of medically underserved patients. Methods. Patients with type 2 diabetes participated in a diabetes self-management program delivered by diabetes educators. We evaluated factors associated with successful goal attainment and the impact of goal setting on glycemic control. Results. During a 3-year period, 488 patients participated in the self-management program and set a total of 2,133 goals. Hispanic patients and those with depression were as successful as others at setting and attaining goals. Goals focusing on medications and healthy eating were more often successfully attained. Successful goal attainment was independently associated with achieving or maintaining an A1C value of < 7.0%. Conclusions. Underserved, largely Spanish-speaking patients successfully set and attained specific goals, with a preference for those focused on healthy eating and medication taking. This evaluation suggests an association between the successful achievement of individual goals and glycemic control.

Project ECHO: replicating a novel model to enhance access to hepatitis C care in a community health center.

Project Extension for Community Healthcare Outcomes (Project ECHOTM) is an innovative telemedicine program that improves patient care by developing and supporting the competence of primary care providers. The Community Health Center, Inc. replicated this model to address significant access issues and improve hepatitis C management and treatment for its patients.

Community Health Centers and the Patient-Centered Medical Home: Challenges and Opportunities to Reduce Health Care Disparities in America

Health care disparities pose an ongoing challenge to the nation. The patient-centered medical home (PCMH) model presents a unique opportunity for community health centers (CHCs) to improve the health of medically underserved communities and reduce health care disparities. Community health centers face ongoing financial and operational challenges, but are well positioned to adopt the PCMH. Health centers have experience collaborating on quality improvement initiatives and possess a strong organizational structure. The culture of CHCs emphasizes cultural competence, team work, and patient-centrism, and is well-aligned with the PCMH model. However, CHCs need more support to make fundamental changes in processes and practice culture. Many of these changes require substantial redesigns that can challenge even the most innovative practices. State and federal policy should focus on providing training, guidance, and payment mechanisms that support PCMH. Taking these steps, the U.S. can achieve the goal that every American receives patient-centered care that is equitable, affordable, and effective.

Using Health Information Technology to Improve Adherence to Opioid Prescribing Guidelines in Primary Care

Objective:To evaluate the impact of a clinical dashboard for opioid analgesic management on opioid prescribing and adherence to opioid practice guidelines in primary care. Methods:A pre/postimplementation evaluation using electronic health record (EHR) data from patients receiving chronic opioid therapy (COT) between April 1, 2011 and March 31, 2013. Measures include annual proportions of COT patients who received urine drug testing, signed an opioid treatment agreement, had a documented assessment of pain-related functional status, and had at least 1 visit with a behavioral health provider. Results:Adherence to several opioid prescribing guidelines improved in the postimplementation year compared with the preimplementation year: (1) the proportions of COT patients with a signed opioid treatment agreement and urine drug testing increased from 49% to 63% and 66% to 86%, respectively. The proportion of COT patients with a documented assessment of functional status increased from 33% to 46% and those with a behavioral health visit increased from 24% to 28%. However, there was a small decline in the proportion of patients prescribed COT from 3.4% to 3.1%. Discussion:Implementation of an opioid dashboard led to increased adherence to certain opioid practice guidelines and a decline in COT. This may be attributable to more efficient team-based pain management facilitated by the dashboard and increased transparency of opioid prescription practices. Health Information Technology solutions such as clinical dashboards can increase adherence to practice guidelines.

Improving Pain Care with Project ECHO in Community Health Centers

Abstract Objective Pain is an extremely common complaint in primary care, and patient outcomes are often suboptimal. This project evaluated the impact of Project ECHO Pain videoconference case-based learning sessions on knowledge and quality of pain care in two Federally Qualified Health Centers. Design Quasi-experimental, pre-post intervention, with comparison group. Setting Two large, multisite federally qualified health centers in Connecticut and Arizona. Subjects Intervention (N = 10) and comparison (N = 10) primary care providers. Methods Primary care providers attended 48 weekly Project ECHO Pain sessions between January and December 2013, led by a multidisciplinary pain specialty team. Surveys and focus groups assessed providers’ pain-related knowledge and self-efficacy. Electronic health record data were analyzed to evaluate opioid prescribing and specialty referrals. Results Compared with control, primary care providers in the intervention had a significantly greater increase in pain-related knowledge and self-efficacy. Providers who attended ECHO were more likely to use formal assessment tools and opioid agreements and refer to behavioral health and physical therapy compared with control providers. Opioid prescribing decreased significantly more among providers in the intervention compared with those in the control group. Conclusions Pain is an extremely common and challenging problem, particularly among vulnerable patients such as those cared for at the more than 1,200 Federally Qualified Health Centers in the United States. In this study, attendance at weekly Project ECHO Pain sessions not only improved knowledge and self-efficacy, but also altered prescribing and referral patterns, suggesting that knowledge acquired during ECHO sessions translated into practice changes.

Improving pain care through implementation of the Stepped Care Model at a multisite community health center

Purpose Treating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center. Methods The Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 preintervention and 4,385 postintervention) cared for at Community Health Center, Inc. Data were collected from the electronic health record and supplemented by chart reviews. Surveys were administered to PCPs to assess knowledge, attitudes, and confidence. Results Providers’ pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing. Conclusion Implementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes.

Impact of dermatology eConsults on access to care and skin cancer screening in underserved populations: A model for teledermatology services in community health centers

Background The clinical outcome of teledermatology with dermoscopy in large‐scale primary care networks remains unclear. Objective We evaluate the impact of implementing a teledermatology consultation program with dermoscopy on a statewide scale, focusing on access to care and skin cancer screening for medically underserved populations. Methods Descriptive retrospective cohort study of 2385 dermatology referrals from primary care from June 2014 through November 2015. Results Before implementation of electronic consultations (eConsults), access to dermatology was limited; only 139 (11%) of 1258 referrals resulted in a confirmed appointment with a median wait time of 77 days. Post implementation, 499 of 1127 consults (44%) were sent electronically, and of those, 16% required a face‐to‐face visit with a median wait time of 28 days. Ten malignancies were identified via eConsults. Overall consult volume remained stable pre‐ and post‐eConsult implementation. Limitations We evaluated eConsults in medically underserved populations seeking care at community health centers. Results might not be generalizable to other populations or in other settings. Conclusion eConsults increase access to dermatologic care and reduce wait times for patients receiving medical care at community health centers. Implementing dermoscopy into teledermatology could increase access to skin cancer screening and treatment for medically disadvantaged populations.

Stepped care model of pain management and quality of pain care in long-term opioid therapy.

Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.