Monitoring health records on tobacco cessation treatment – 3/14/11

Q: A Community Evaluation Workgroup is interested in monitoring the Federally Qualified Health Centers (FQHCs) and low income clinics that use electronic medical records or electronic health records in our area to see their responses to the questions:

1. How many patients were assessed for tobacco use?
2. How many patients were counseled for tobacco use?

Since these two questions are now tied into the bonus structure, we would like to determine the baseline and monitor it see if there is any increase. Of course we can ensure privacy to all clinics that we would not release the numbers associated with their clinics - it would only be aggregated to provide anonymity.

Have any others done this before? Are there template letters out there to get permission from the clinics to participate? Are there any words of wisdom or caution about embarking on this effort?

A:

1. Iowa/Nebraska Primary Care Association: The Primary Care Association in Iowa is the association of all the Federally Qualified Health Centers. Each state has a Primary Care Association, which can serve as a resource for connecting with and contacting FQHCs. In Iowa, the Department of Public Health (IDPH) issued a Request for Proposals to establish a low-income tobacco cessation program in a network of clinics that primary served low-income and uninsured patients. The Primary Care Association was selected to manage the project, which began in 2008 (additional background information about the program is attached) and has involved fourteen FQHCs. As part of the project, the IDPH set goals for tobacco use assessment over the project period involving both participants and non-participants in the tobacco cessation program. The evaluation was conducted by the University of Northern Iowa and for this measure, and was based on chart reviews on a semi-annual basis.
    
   The majority of FQHCs have had an electronic patient population management registry since 2007, and are now working to implement electronic medical records. With the implementation of the electronic medical records and a direct HL7 exchange of information between the EMR and registry, it will be easier for our FQHCs to track tobacco use status electronically as they will no longer have to data enter the tobacco use status of patients into the registry.
    
   With the tracking requirement from the IDPH, most of the FQHCs now treat tobacco use status as a vital sign (similar to height, weight, etc.) and based on the last chart review data were capturing the tobacco use status of every adult patient (whether a participant or non-participate in the program) over 90% of the time. With Meaningful Use, our FQHCs will need to start capturing this information for individuals age 13 and older, but this should be an easy change for them as their nursing staff or medical assistants are used to collecting this information as part of their work-ups.
    
2. Massachusetts: For several years, Massachusetts offered funding and technical assistance to community health centers to integrate brief tobacco use interventions recommended by the U.S. P.H.S. Clinical Practice Guideline into clinic workflows and information systems. Once health centers had integrated the recommended interventions into their systems, they were expected to submit reports on the tobacco use screening and brief interventions delivered by adult primary care providers and that were documented in the patient record.
    
   Among the many lessons learned from this project were that implementation of systems-level improvements usually takes much longer than anticipated and that health information technology issues can be very complex. For example, while a community health center (CHC) may use electronic medical records for patient care, they may not have the HIT capacity to generate performance reports from the information collected in those records.
    
   If you don't already have this information, you may want to consider a survey of CHCs to determine what, if any, tobacco use interventions health care providers are expected to deliver and document in the EMR. Also, it would be useful to know if tobacco use intervention performance measures are in place and if tobacco use is included in the CHCs clinical quality improvement process.
    
   The Massachusetts Tobacco Cessation and Prevention Program has recently developed an electronic survey for CHC medical directors to access tobacco use screening and brief intervention protocols currently in place in Massachusetts CHCs.
    
3. Michigan/Michigan Primary Care Association: Michigan collects the data differently.
    
   Michigan 2009 Data (2010 data will be available in August 2011):
    
   Universal Data System used in all FQHCs asks:
      Number of patients diagnosed with tobacco use disorder: 18,537
      Number of visits to patients diagnosed with tobacco use disorder: 41,173
    
   Service Category - Smoking and tobacco use cessation counseling:
      Number of users: 1,333
      Number of encounters: 1,971
    
   Information is not collected from all the electronic health records. Some may have used this as a clinical quality measure.
    
4. Missouri: The Missouri Comprehensive Tobacco Control Program collaborates with the Diabetes Prevention & Control Program and the Heart Disease & Stroke Program to work with federally qualified health centers.
    
   In 2005, a scoreboard report was incorporated in the contract between the Missouri Department of Health and Senior Services and the Missouri Primary Care Association. The scoreboard report provides a summary report of the individual federal qualified health centers (FQHCs) progress in achieving Health Resources and Services Administration (HRSA), National Committee for Quality Assurance (NCQA) and Centers for Disease Control and Prevention (CDC) goals, along with a comparison of goal achievement by all Missouri FQHCs. The scoreboard is used within quality circles to provide an at-a-glance comparison of performance goals. The scoreboard is calculated on a quarterly basis and sent to FQHC Executive Directors to show their progress in the collaborative. The scoreboard report is a snapshot in time that indicates how well each FQHC is doing in meeting established goals.
    
   In order to create the scoreboard, the attached PopTotal file was created from data received from each participating FQHC. Click here to view the file.
    
   Based on the results of their scores, FQHCs create Plan/Do/Study/Act (PDSA) cycles to improve their scores. Each participating FQHC in the collaborative is required to perform four (4) PDSA cycles per contract year – two (2) June through November and two (2) December through March. Click here to view an example of a Quality Improvement Worksheet submitted by one of the participating FQHCs.

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Partner Response:

Multi-State Cessation Collaborative for Health Systems Change: Members of the Multi-State Cessation Collaborative for Health Systems Change [to address tobacco use] have experience working with FQHC and ambulatory clinics to document and report tobacco use identification and intervention data. The Collaborative is also working with experts to advance members’ understanding of Stage 1 and downstream meaningful use requirements. The Collaborative recently submitted comments on Stage 2 proposed rule(s) for tobacco measures.

Editor’s note: The Multi-State Cessation Collaborative is a collaborative of tobacco control programs working to facilitate sustainable changes in health care systems within our states and nationally in order to reduce tobacco use and prevalence. Click here for more information.

The Collaborative has hosted webinars on Meaningful Use, Electronic Medical Records, and other related topics; more information, materials, and recordings are available here.

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