Projects

Our Current Projects

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Clinical Quality Metrics Registry (CQMR)

This project connects the Oregon Health Authority with OHSU experts in health informatics to assist with various aspects of clinical quality measure reporting, including but not limited to technical assistance, data review, and providing consultation on clinical quality metrics registry planning.

Funded by Oregon Health Authority

CQMR Website

CPC

Comprehensive Primary Care initiative (CPC)

The Comprehensive Primary Care (CPC) initiative is a large innovative effort to redesign care delivery and provider payment from the Centers for Medicare and Medicaid Services’ (CMS) Center for Medicare and Medicaid Innovation (CMMI). This four-year multi-payer initiative launched in October 2012 to strengthen primary care. Through this initiative, CMS has leveraged resources from roughly 30 payers in four states (Arkansas, Colorado, New Jersey and Oregon) and three regions (New York’s Capital District and Hudson Valley, Ohio and Kentucky’s Cincinnati-Dayton region, and Oklahoma’s Greater Tulsa region) to support transformation through enhanced payments, data feedback, and learning activities in 492 primary care practices serving approximately 315,000 Medicare beneficiaries and more than 2.5 million patients.

CMS offered population-based care management fees and shared savings opportunities to support these five core comprehensive primary care functions:

  • providing care management for those at greatest risk
  • improving health care access and continuity
  • planning care for chronic conditions and preventive care
  • coordinating care across the medical neighborhood
  • patient and caregiver engagement. using health information technology to support population health

The initiative is testing whether focus on these functions, along with the continuous use of data to guide improvement, and the use of health information technology to support population health, can achieve improved care, better health for populations, and lower costs.

Participating CPC practices receive curriculum developed by CMMI learning and diffusion experts, as well as targeted coaching and practice facilitation from a regional technical assistance (TA) team. Regional TA teams provide direct assistance and develop and implement a local curriculum using three modalities: a series of group meetings (in-person or virtual); a virtual webinar series; and specific goals for monitoring study milestones. The TA team in Oregon is led by Dr. David Dorr, with additional supporting faculty, Dr. LJ Fagnan, Dr. Evan Saulino, Dr. Cherie Brunker, and Dr. Ronald Stock as part of the leadership team.

Funded by TMF Health Quality Institute

CPC Website

Improving Implementation of Risk Prediction in Primary Care

This project aims to improve primary care practices’ ability to successfully risk stratify their patient populations, in order to tailor interventions to current and future high-risk high-need patients. This mixed-methods study involves a quantitative analysis of factors that affect the validity and usefulness of risk stratification, and a qualitative analysis of risk stratification approaches and the potential for their improvement. The outcome of the project is intended to be a practical approach to risk stratification implementation aimed first at ambulatory practices, and second, at those designing and evaluating programs with risk stratification as a core component of their methodology. The qualitative aspect of this study is being co-led by Dr. Deborah Cohen within the OHSU Department of Family Medicine.

Funded by The Commonwealth Fund

Patient Centered Primary Care Home (PCPCH) Web System

Our team hosts and maintains the Patient Centered Primary Care Home (PCPCH) recognition web application. Initially implemented in January 2014, we now host, update, upgrade and enhance the recognition web application.

Funded by Oregon Health Authority

PCPCH Website

TOPMED

Transforming Outcomes for Patient-centered Medical home Evaluation and reDesign (TOPMED)

TOPMED is a two-arm, cluster randomized controlled trial, investigating how to transform primary care clinics in order to achieve high value elements (HVEs). Both arms received quality improvement guidance, including external practice facilitation, IT-based milestone reporting, and financial incentives based on self-selected QI goals. Intervention clinics were directed to select their quality improvement goals from a list of HVEs, which have been demonstrated in the literature and by stakeholders to improve patient outcomes and lower costs. Results include patient satisfaction, utilization, costs, and improvement in quality measures. This study had practice facilitation support provided by the Oregon Rural Practice-based Research Network.

Funded by the Gordon and Betty Moore Foundation

TOPMED Website

Collaborations

Big Data to Knowledge (BD2K) Skills Development

The focus of the NIH Big Data to Knowledge (BD2K) program is to support the research and development of innovative and transforming approaches and tools to maximize and accelerate the integration of Big Data and data science into biomedical research. The OHSU Department of Medical Informatics has several funded BD2K grants that are focused on enhancing data science training in biomedical research, as well as supporting the development of new methods. The OHSU BD2K Skills Courses have provided a series of training opportunities for a variety of learners. This training initiative is led by David Dorr, Melissa Haendel, and Shannon McWeeney. The individual offerings of the course are intended to progress from novice to expert.

Funded by the National Library of Medicine at National Institutes of Health

BD2K Website

Clinical Information Needs of CHCs for HIT (CLINCH-IT)

This study is in collaboration with the OHSU Department of Family Medicine, with Dr. Deborah Cohen as Principal Investigator. We will examine the nature of cognition, task distribution, and clinical work in various health care delivery settings, and will attempt to address current knowledge gaps regarding our understanding of health care providers' information needs and health care decision making processes, both individually and collectively. The aims of this project are to:

  1. Identify clinicians and clinical care teams' information and decision making needs when coordinating care for complex patients
  2. Identify their information needs regarding patients' social determinants of health
  3. Identify design principles and develop health IT tools to meet these needs.

Funded by the Agency for Healthcare Research and Quality

H2N

Healthy Hearts Northwest (H2N)

Our Specific Aims (with RE-AIM factors) are to:

  1. Identify, recruit and conduct baseline assessments in 320 small and medium primary care practices across the geographically contiguous region of WA, OR and ID. (REACH)
  2. Provide comprehensive external practice support to build QI capacity within these practices. (IMPLEMENTATION & ADOPTION)
  3. Disseminate and support the adoption of PCOR findings relevant to the ABCS quality measures. (EFFECTIVENESS)
  4. Conduct a rigorous evaluation of the effectiveness of providing external practice support to implement PCOR findings and improve ABCS measures. (EFFECTIVENESS)
  5. Assess the sustainability of changes made in QI capacity and ABCS improvements and develop a model of dissemination and primary care practice support infrastructure. (MAINTENANCE)

Funded by the Agency for Healthcare Research and Quality

H2N Website

Improving Quality by Maintaining Accurate Problem Lists in the EHR (IQ-MAPLE)

The overall goal of the IQ-MAPLE project is to improve the quality of care provided to patients with several heart, lung and blood conditions by facilitating more accurate and complete problem list documentation. In the first aim, we will design and validate a series of problem inference algorithms, using rule-based techniques on structured data in the EHR and NLP on unstructured data. Both of these techniques will yield candidate problems that the patient is likely to have, and the results will be integrated. In Aim 2, we will design CDS interventions in the EHRs of the four study sites to alert physicians when a candidate problem is detected that is missing from the patient’s problem list – the clinician will then be able to accept the alert and add the problem, override the alert, or ignore it entirely. In Aim 3, we will conduct a randomized trial and evaluate the effect of the problem list alert on three endpoints: alert acceptance, problem list addition rate, and clinical quality. This study is a collaboration with Brigham and Women's Hospital, with Dr. Adam Wright as the Principal Investigator. Other investigator sites include Holy Spirit Hospital and Vanderbilt University.

Funded by the National Heart, Lung, and Blood Institute

Knight Cardiovascular Institute (KCVI) Analytics

In 2014, faculty from the Knight Cardiovascular Institute and the Department of Medical Informatics & Clinical Epidemiology (DMICE) formed a new collaboration with the goal to elevate the institute’s capabilities to analyze data and information essential to improving cardiovascular health outcomes and reducing cardiovascular health care costs. The main goals are to address top-priority quality measure needs, develop expertise in the areas of data requirements, sources and normalization, expand data analytics and reporting capabilities, use data to make better informed institutional decisions, and establish a process to advance research agendas at the intersection of cardiovascular medicine and informatics. This is a collaboration with the Informatics Discovery Lab within DMICE.

Funded by the Knight Cardiovascular Institute

Workforce Training to Educate Healthcare Professionals in HIT

The ONC Health IT Curriculum provides a national resource that gives community colleges and other institutions of higher education access to a wealth of curricular materials on health information technology (HIT). The materials were originally developed to train HIT workforce roles that could help hospitals and providers to achieve meaningful use of the electronic health record (EHR) and qualify for incentive payments. The objective of our current efforts is to update the materials, especially in the emerging topical areas, since the original project ended in 2012, and to expand the curriculum to train a larger and more diverse workforce. With the expertise of Dr. William Hersh, Principal Investigator of the OHSU ONC HIT Curriculum Development Center; Dr. David Dorr, an expert in population management, care coordination, and HIT; and several other faculty, we are updating and expanding these materials, and currently working on training a more diverse group of incumbent health care workers who develop, implement, and support HIT, including clinical informaticians, health information management specialists, IT specialists, clinical champions, care coordinators, and panel managers.

Funded by Office of the National Coordinator

Past Projects

Multiple Chronic Conditions

The goal of this project is improvement of risk stratification methods and predictions of outcomes for patients with multiple chronic conditions. Specifically, there are three aims: 1) to compare accuracy and completeness of diagnoses through manual validation of a “gold standard” patient-diagnosis dataset; 2) to explore whether the modest predictive validity of standard risk scores is due to variability in the data source and validity; and 3) to create optimized risk prediction models based on the knowledge about comorbidity data gained in the first two aims using advanced machine learning algorithms and data transformation approaches.

Funded by the Agency for Healthcare Research and Quality

Patient Centered Medical Home for Older Adults

The Network comprises a group of experts in geriatrics and primary care with the vision to transform PCMHs to recognize, facilitate, encourage, and ultimately improve the care of older adults and their caregivers. Over a two-year period, the Network will identify and refine selected topics of critical importance to the field of geriatrics in PCMHs. Three pilot projects have been planned for 2015-2016 based on an initial evaluation of needs.

Funded by the Gerontological Society of America

PCMH Website