The New York City Department of Health and Mental Hygiene(NYCDH) has become known for its innovative approaches to numerous public health issues in the nation’s largest metropolitan area. Indeed, when it came to improving the health of African-American communities, NYCDH officials realized that they had a special advantage in their existing relationships with black churches in Brooklyn and Queens, churches with strong ties to parishioners who otherwise tend to live at the margins of the reach of the public health infrastructure.
As a result, leaders of five of those churches—two are Seventh-Day Adventist, two are Pentecostal, and one is Baptist—readily agreed when they were asked to participate in the NYCDH’s Community Health Dashboard Project, which aims to improve blood pressure and other health indicators.
“Conceptually, this program came out of conversations that our staff were having with physicians around the time we were running a large pay-for-performance program based on EHR-derived quality measures,” says Thomas Cannell, the department’s director of community technology. “And the idea was, you’d pay a doctor more if they could keep a patient’s blood pressure under control. But doctors perceived accurately that they could be the world’s best doctor, yet still, it wouldn’t mean that the blood pressure of their patients would all be under control, because blood pressure management relies on so very many social and environmental determinants of health.”
As a result, Cannell and his colleagues decided to reach out to five local, predominantly African-American churches, in order to take a first stab and improving blood pressure monitoring and management in the community. In October 2010, the department went to a group called the Brooklyn High Blood Pressure Faith-Based Task Force, a collaborative of churches involved in monitoring parishioners’ blood pressure readings. About 15-20 churches participate regularly in the task force, while another 10-15 participate occasionally. In addition, Cannell says, many local churches run their own programs in that area.
Ultimately, Cannell and his colleagues at the NYCDH reached out to the Toronto, Ontario-based NexJ Systems to adapt that company’s enterprise customer relationship management (CRM) technology to this particular situation.
Thomas Cannell spoke in late May with HCI Editor-in-Chief Mark Hagland regarding the initiative that came out of that first meeting with that local task force, and the results so far from the effort. Below are excerpts from that interview.
How did this initiative evolve forward out of the initial meeting you and your team had with the Brooklyn High Blood Pressure Faith-Based Task Force?
We weren’t particularly interested in being comprehensive in our initial effort; we just wanted to reach out to them. So we met with them and talked with them about the issues doctors were engaged in. And in that meeting, they immediately asked, can you help us do follow-up? Because we take blood pressure readings, and put them on pieces of paper, and we’ve got boxes filled with file cards, and we struggle with continuity. And we didn’t have any money, so we couldn’t promise too much. But we said, we’re your health department, and we love the work you’re doing, and we want to try to help you. And I have a background in doing community-based development through churches.
The team that developed the Community Health
Dashboard pilot project at the NYCDH (left to right):
Thomas Cannell, Natoya Worrell, Kiana Bridgeman,
Jessica Richman, Jessica Ohlssen (foreground), and
Hindia Omar-Miller (background, right)
Then what happened?
We did some follow-up conversations with the churches. And we had received a grant from New York state, a HEAL [Healthcare Efficiency and Affordability Law] grant for developing health information exchange. There’s a provision in that grant for developing personal health information, and we took less than $100,000 out of that grant, and used that to fund this program back in April 2011. We said, we want a personal health record in which someone can record their blood pressure; one in which a person can share it with someone else; and we want a PHR [personal health record] system where many people can share their blood pressure with a lay community health worker, and where that community health worker can see all the information not only on an individual level, but also aggregated. So we put out an RFP [request for proposal], but called it an RFI [request for information], since we weren’t able to indicate precisely how much we could spend.
How many vendors participated in the RFI?
I think we got about 24 letters of intent, and then we got about 13 or 14 full applications. And we reviewed those, and we narrowed it down to four demonstrations. People came in and showed us their capabilities. And, based on all the criteria we’d laid out, we selected Dossia [an employer-based information technology collaborative that offers a personal health management system], and as a subcontract to Dossia, Dossia proposed that NexJ would build an app that would integrate with Dossia, and the NexJ interface is what the lay health worker sees.
When the lay health worker logs into the NexJ HealthTracker, they have three different operative tabs across the top. One says ‘participants,’ and when you click on that, you see listed across a line, all the people in the church who have signed up and have shared their blood pressure, weight, or steps walked. So this is basically like a digital file box. It’s really not that different from flipping through a file box, except that when you click on ‘blood pressure,’ it brings up to the top the people with the highest blood pressures. You could do the same thing with an Excel spreadsheet, but it wouldn’t be as manipulable.
Now, these lay health workers had previously had training with what’s called “Keep On Track.” And we advise them that when someone has a blood pressure taken and it’s above a threshold that we regard as dangerous, something like 190 over 100—averaged across two readings—our advice is that that person should seek medical advice that day. If it’s above 140 over 90, or borderline, our counsel is that that person should have a regular doctor, take their medications as prescribed. The volunteers don’t get into the question of what the medication is, even though many of them are nurses; instead, they focus on referral and counseling. As we move forward with this program, what we’d like to do is to develop a protocol where the intervention is not just counseling, but very specific referrals to programs.
Do you have any metrics yet on the number of blood pressure readings that are on these laptops so far?
Four churches had completed their trainings in March, and by the end of April, 72 people at the four churches had signed up, and I expect the number to reach 100 by the end of May. Signing up means you sign up for the Dossia Personal Health Record and click the permission to enable the NexJ app.
Is the information being kept by the health ministries? Or are some people actually going to maintain their own PHRs?
We don’t know yet exactly how that will shake out; it’s one of the things we’ll learn by the end of this phase of the pilot in July, as we do some listening sessions and user discussions. But we very purposely purchased the technology with a clear signal that it should work both for someone who was computer-literate and wanted to use a computer and also for someone who was not.
This clearly should be replicable elsewhere, right?
Yes. If anything, the institutionalization of programs in faith-based organizations is moving forward. For example, the city of Memphis has a very strong relationship with Methodist Hospital down there. And so there are many organizations, including parish nursing organizations, that could take this up, if it would prove to be usable and valuable.
And let’s say, OK, I’m going to my church and am having my blood pressure taken, and it’s uncontrolled, and how does that relate to my doctor? I was determined that we not approach this as a health information exchange puzzle, because my feeling was that we wouldn’t really progress very far in the short term. So right now, we’ve given the churches printers, so they’re able over the next month to start printing out cards with the blood pressure charts on them that people can take into their doctors’, so the doctors can look at the blood pressure readings. And into the future, obviously, if the doctors want to see these readings in some automated, standards-based exchange, we could do that. That’s sort of the main thing that Dossia does; so it’s doable; we’re just waiting for a use case to emerge.