A Comparison of Hemorrhagic and Ischemic Strokes among Blacks and Whites:
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1 A Comparison of Hemorrhagic and Ischemic Strokes among Blacks and Whites: A Population-Based Study That Will Demonstrate Issues Surrounding EHR Access and Research Brett Kissela, MD, MS Professor Vice-Chair of Education and Clinical Services Department of Neurology, University of Cincinnati Member, Greater Cincinnati/N. Kentucky Stroke Team
2 Plan EHR: Clinician s perspective EHR: Research perspective Stroke Team examples: old and new GCNKSS = Greater Cincinnati/Northern Kentucky Stroke Study Framing of some issues for discussion today Summary
3 Point of View: Clinician I am very much in favor of the EHR Good in many ways for patient care; i.e. safety Definitely has not made care easier to provide I am definitely less efficient in clinic
4 EMR pros and cons: PROS Safer for patients All information in one place Easy to sort and find information No missing charts All typed/legible notes Better provider communication? CONS Slow to access (logins) Slow to enter data Looking at screen, not patient Training! Complexity (Epic) Risk of copying info incorrectly HIPAA concerns
5 A true security story A neurology MA was fired for HIPAA violation All providers have full access to all patients in system Tracking system in background can find inappropriate access If accident, log in but then log out right away She logged in and then looked for 8 minutes Algorithm for how to know if someone s access is appropriate or not
6 Clinician (cont.) Stroke team clinical care = acute stroke care for every hospital in city Multiple Systems = Duplicative training! HealthBridge = a unique resource that will ultimately allow me to access the electronic medical record at every system (via their portal) I ll be one of the lucky few who can do this; Epic doesn t talk across systems
7 Research & Medical Records: Example 1 GCNK Stroke Team (NIH funding) TASK: Acute stroke studies, multi site study nurse needs to access patient s chart after enrollment in study to gather data OLD WAY: go to medical records and ask for it They can ensure IRB approval, HIPAA authorized then can provide only the chart that is needed NEW WAY: varies by site show consent/waiver, get record (printed copy of chart) or full access (but keep log for some)
8 Research & Medical Records: Example 2 NIH-NINDS R-01 NS30678, Hemorrhagic and Ischemic Strokes Among Blacks and Whites ; in progress with Dawn Kleindorfer, MD Multiple PI s
9 Population representative of U.S. - 15% African American versus 13% for U.S., economic and education distribution are also quite similar
10 RESEARCH NETWORK Hospitals 1 University 3 Teaching 1 Children s 13 Community also provide acute stroke consultation for possible acute intervention Greater Cincinnati / Northern Kentucky Stroke Laboratory
11 GCNKSS First six months of inpatient screening for blacks only - pilot study (Stroke, 1998) = Phase I Next 12 months (7/1/93 to 6/30/94) - prospective screening of outpatient sites and all hospital encounters of possible stroke = Phase II Repeat in 1999 = Phase III Prospective cohort for outcomes and genetics In all subsequent phases Repeat in 2005 = Phase IV Repeat in 2010 = Phase V
12 Sampling Methods Retrospective Ascertainment All inpatients with codes (1st and all 2nd dxs.) Eliminated after initial experience Hot Pursuit for cohort All ED log sheets All public health clinics All hospital-based outpatient clinics All five coroner offices
13 Sampling Methods ( numbers) Random sample of 50 of the 878 primary MD offices in five counties using Yellow Pages Random sample of 25 of 193 nursing facilities
14 Research & Medical Records: Example 2 GCNKSS: OLD WAY: go to medical records and run many lists of admitted patients by ICD-9 code (10,000-14,000 medical records); They ensure IRB approval, HIPAA waiver Manual crosschecking for duplicates Hundreds of hours of gathering charts for physical review on site by small army of study nurses, medical record abstraction Physician review 4000 abstracts
15 Research & Medical Records: Example 2 GCNKSS: NEW WAY: electronic list run by system after verifying IRB approval, HIPAA waiver Record review: varies by site/system show consent, get record (printed copy of chart) or put into queue to access electronically or full access (but keep log for some) Latter two options for record review do not require on site nursing
16 Age-Specific Risk of First-Ever Stroke in Blacks as Compared to Whites ( ) Risk Ratio Blacks have higher risk Blacks have lower risk < Kissela, et al. Stroke 2004 Years BM vs. WM BF vs. WF
17 Stroke Incidence in US Our data from , generalized to the U.S. population, suggest that 705, strokes occur in the U.S each year 616,000 ischemic strokes 67,000 intracerebral hemorrhages 22,000 subarachnoid hemorrhages Approximately 500,000 first-ever strokes Kissela, et al. Stroke 2004
18 Including Out-of-Hospital Type Black White 1993/ / All subtypes 355 (318, 392) 334 (300, 368) 330 (298, 362) 227 (217,238) 264 (252, 274) 209 (199, 218) Ischemic 303 (269,337) 291 (259, 323) 294 (263, 324) 206 (195,216) 240 (229, 251) 180 (171, 189) ICH 57 (42, 72) 58 (44, 70) 57 (44, 70) 26 (22,30) 30 (26,33) 30 (26, 33) SAH 15 (8,22) 15 (8, 21) 19 (12, 26) 8 (6,11) 9 (7,11) 7 (6, 9) Kleindorfer, et al. Stroke 2010.
19 Age over time: First-Ever Stroke < 45 y 1993/ Age (SD) 71.3 (13.6) 70.9 (14.4) 68.4 (15.4) % < 45 yo 4.5% 5.5% 7.3% Black White 1993/ / Rates 45 (30-60) 48 (33-64) 57 (40-74) 12 (9-15) 17 (13-21) 25 (20-30) Kissela, et al. in press, Neurology 2012
20 Race-specific Risk Ratios for First Stroke: Diabetic Pts vs. Non-Diabetic Pts ( ) Kissela, et al. Diabetes Care, 2005
21 A Pilot Population-Based Outcomes Study using a Health Information Exchange: Preliminary Feasibility Results Brett Kissela, MD, MS Professor of Neurology Greater Cincinnati/Northern Kentucky Stroke Team Cerebrovascular Disease & Stroke Center
22 Introduction Post-stroke outcome studies: Disposition Mortality direct follow-up interview of stroke victims Expensive, time consuming and can lead to a biased cohort There is a need for a population-based stroke outcomes study
23 Introduction GOAL: to evaluate the feasibility of facilitating outcomes assessment using a Health Information Exchange (HIE) HIE (HealthBridge): regional network for sharing healthcare data among providers HYPOTHESIS: HIE-facilitated cohort identification with phone-call follow-up would enable more efficient populationbased outcomes determination compared to traditional approaches
24 Methods All regional ischemic strokes during 2010 identified by screening all ER/hospital admissions for stroke cases (HOT PURSUIT) HIE computerized algorithm--filtered by key words for stroke and zip code human-screening to identify actual stroke cases 2000 admits, 60 possible, 20 stroke Cases were then enrolled into one of two cohorts in a non-random fashion
25 Methods First 500 cases were assigned for hot pursuit and in-person interview (traditional cohort) Those cases not enrolled in the traditional cohort assigned to have HIEdata review and phone call interview (HIE cohort) at 3 months only Primary endpoints of the pilot: feasibility of contacting patients and assessing outcomes by phone time spent and cost - not be discussed here
26 Methods Cooperation rate #contacted / # eligible Completion Rate: # of completed interviews / # contacted
27 Results 17,671,258 HIE messages about 1,967,415 unique patients seeking care at hospitals within the study region in 2010 The computerized algorithm identified 5,082 potential strokes for human review
28 Results Traditional Cohort In-person interviews were attempted on 793 subjects 689 eligible for interview 516 agreed to participate in the traditional cohort. Immediate cooperation rate was 75% 408 completed a 3-month follow-up interview (approximates 59% completion rate)
29 Results HIE cohort For the HIE cohort, 581 subjects were identified for potential phone interviews 491 calls were placed at 3 mo post-stroke 320 subjects were reached 204 completed the interview Cooperation rate was 52% Completion rate was 64% Quality of outcomes data were similar with both approaches
30 Summary of GCNKSS Almost 20 consecutive years of NIH funding with important findings regarding temporal trends in stroke Incredible THANKS to all local hospital personnel who have helped Addition of HealthBridge informatics facilitated pilot study for populationbased outcomes after stroke We are only just beginning to consider the research possibilities in our community with the EHR and HealthBridge
31 Issues for today What is the proper balance between HIPAA compliance and ability to do research? Is it possible to allow access and monitor somehow in background for HIPAA compliance?
32 Issues for today Can we agree upon basic principles for research access to EHR across the community? Would be beneficial to IRB s at all systems Would be beneficial to researchers This is a crucial topic that is causing angst Few projects will have needs like our stroke studies, but still a worry for EVERYONE
33 Issues for today HealthBridge?? One system created by city-wide collaboration that can bridge multiple systems Clinically, patients FREQUENTLY go to different hospital systems or get transferred Could share info across health systems Could make Cincinnati the epicenter of epidemiology research, similar to Olmstead County (Mayo) Endless possibilities for quality of care improvements and research
34 Summary EHR: Changing the way we practice medicine I love me some Epic Positive change but not without limitations clinically For research: informatics and EHR could revolutionize the research enterprise in our city, especially epidemiology Good for Cincinnati s economy, research/medical community, and community health We have amazing city-wide collaboration, this conference is a beginning for trying to find consensus
35 Questions? Discussion?
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