NYC Tracking Population Health

New York City is developing the NYC Macroscope, an EHR-based population health surveillance system to track conditions managed by primary care practices to focus on chronic conditions as they relate to public health. To date, there has been relatively little focus on using EHRs for population health surveillance in spite of the fact, that 72 percent of office-based medical practices nationwide use some kind of EHR system.

By having primary care practices involved and by improving population health surveillance, health officials will be able to strategically target resources and then provide data to guide and evaluate public health initiatives and policies. This can be accomplished by using EHRs to provide rapid access to large volumes of real-time standardized health data such as body mass index and blood pressure as well as deliver information related to clinical preventive services and chronic disease management.

EHRs that have been constructed with population health management in mind have the ability to complement and expand the capacity of existing data collection systems by capturing interactions between physicians and patients economically.

The NYC Macroscope will rely on the NYC Health Department’s “Primary Care Information Project” (PCIP) which in 2012 receive data from more than 600 ambulatory practices and 2,500 providers, representing 1.5 million patients.

PICP retrieves data using the Hub Population Health Network or referred to as the “Hub” which enables PCIP to question primary care practices. At that point, practices on the “Hub” can return total aggregate counts to a secure centralized site without transmitting any patient identifiable data.

Local, regional, national governments, large healthcare organizations, insurance companies, and academic research centers are in the early stages of learning how to use aggregated data from EHRs to monitor health and then use the information to inform healthcare policies and programs.

To develop the timetable, the NYC Health Department with support from CUNY SPH has developed a planning document “Developing an Electronic Health Record-Based Population Health Surveillance System.”

The second phase of the project in progress from June 2013 to May 2014, will collect pilot data on select health indicators such as chronic disease risk factors, chronic disease prevalence and management, behavioral health, and immunizations.

The third phase to be conducted from June 2014 to June 2015 will analyze and validate NYC Macroscope prevalence estimates and issue a companion report presenting the findings and lessons learned.

The lessons learned will be useful to other agencies and researchers interested in using EHRs to monitor population health.  These lessons can also help in national efforts to interpret and use EHR data, apply standards to EHR data, and capitalize on the exchange of public health-oriented data.

For more information, go to www.nyc.gov and search for nycmacroscope or email nycmacroscope@healthl.nyc.gov.