SE Minnesota Beacon Enabling Population Health Research

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1 SE Minnesota Beacon Enabling Population Health Research Minnesota ehealthsummit June 13, 2013 Research into Practice 3:00pm Session Lacey Hart, MBA, PMP Conflict of Interest Disclosure: Speaker has no real or apparent conflicts of interest to report.

2 Community of Practice focusing upon delivering High value community based care delivery model SE Minnesota Beacon Community

3 Communities of Practice

4 Connectedness Understanding

5 Drivers for Data Repository Establishment and utilization of the community based clinical repository for the Beacon program. Two driving factors for the repository: Population Management Infrastructures/environment & project beyond the grant

6 Repository Requirements Correlate patients, students, and PH cases Identified & anatomized patient access Merge & unmerge patient EMR data to accurately identify patient s for clinical care. Support complex access authorization matrix to protected patient information Easy access to various authorized data sets for reporting and analytics requirements Secure, audited, scalable, cost efficient

7 In Scope Phase 1 Aggregation of patient health information Patient Demographics (including ZIP code and age) Vital Signs (including blood pressure measurement Laboratory Findings ED Visit information from CPT coding or Visit codes Patient cross correlations Submission of patient clinical information to provider population health solutions

8 Clinical Data Repository aka Community Data Repository Hosted at Regenstrief Institute Site Clinical Repository Research Data Repository Population Management Quality Measures Reporting Research Population Management Error handling Point of Care (Future Use)

9 Participation Local Public Health (11 Counties: Dodge, Fillmore, Freeborn, Goodhue, Houston, Mower, Olmsted, Rice, Steele, Wabasha, Winona) Mayo Clinic Rochester (Rochester, Kasson) Mayo Clinic Health System (71 locations) Olmsted Medical Center (Byron Clinic/Chatfield Clinic/Pine Island Clinic/Plainview Clinic/Preston Clinic/Rochester NW Clinic/St. Charles Clinic/Spring Valley Clinic/Stewartville Clinic/Wanamingo Clinic) Winona Health (Winona, Lewiston, Rushford) In progress: Allina Owatonna (Faribault & Northfield TBD)

10 Regenstrief INPC The Indiana Network for Patient Care (INPC) is a centrally managed, federated clinical data repository. Thus each institution s data is physically located on separate digital storage media. Each patient s data is protected in accordance with HIPAA guidelines for privacy and security. The primary way that data flows into the INPC is as HL7 messages. The HL7 messaging standard permits structured and encoded health care information to be exchanged between computer applications. This standard specifies message formats to represent various categories of health information, such as: Order Entry and observation Reporting.

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12 Current Data Elements Patient Demographics Patient id Patient name Patient birth Patient gender Patient ssn Patient phone Patient marital status Patient religion Patient address Encounter Data Location Admit reason Admit date Discharge date Attending physician Diagnosis Procedures Lab Data Lab test batteries Lab results, units, reference ranges In Progress: Medications & Vital Signs Patient Reported Outcomes

13 CDR Stats Newest counts for the Minnesota CDR as of Total number of unique patients: 1,140,814 Currently ~11% overlap Total number of unique patients with an encounter (visit) record: Total number of unique patients with a clinical_variable record (includes lab results as well as various other data types): Total number of records in the clinical_variable table:

14 In Reach Social Worker

15 Public Health Surveillance

16 Community Data Repository

17 Minnesota Research Authorization (MRA)

18 Expanded Chronic Care Model: Integrating Population Health Created by Barr, V. et al. (2002). Adapted from Glasgow,R., et al. (2001) Milbank Quarterly, 79(4), and World Health Organization, Health and Welfare Canada and Canadian Public Health Association. (1986).

19 CENTER FOR THE SCIENCE of HEALTH CARE DELIVERY Population Health Science Program 2012 MFMER slide-18

20 Population Health Science Program Mission Statement: Strengthen local data and research capacities and leverage existing healthcare delivery and public health systems, community assets, and data resources to cultivate a program of research in population health and build an evidence base to prevent disease, promote wellness, and protect population health MFMER slide-19

21 PHSP: Foundational Initiatives Rochester Epidemiology Project Employee and Community Health Research Initiative Beacon Data and Infrastructure 2012 MFMER slide-20

22 Populations Total Populations Geopolitically defined Sociodemographically defined Patient Populations As per diagnosis As per provider or service Populations at Risk (as per risk factor) Genomic risk Behavioral risk Diagnostic risk 2012 MFMER slide-21

23 Focus on Prevention Primary Prevention Tobacco Control Immunization Prior to disease Secondary Prevention Cancer Screening Early disease Tertiary Prevention Chronic Disease Management Chronic disease 2012 MFMER slide-22

24 Myocardial Infarction & Sudden Cardiac Death in Olmsted County, MN, Before and After Smoke-Free Workplace Laws (18-month calendar period before/after) Implementation of smoke-free ordinances was associated with a significant decrease in MI incidence (33% decline) Magnitude not explained by community concurrent interventions or changes in known CV risk factors SHS exposure should be considered a modifiable risk factor for MI Smoke free ordinances implemented on 2 different dates January 1, 2002: smoke-free restaurant law (Ordinance 1) October 1, 2007: all workplaces became smoke-free (Ordinance 2) Hurt RD, Weston SA, Ebbert JO, McNallan SM, Croghan IT, Schroeder DR, Roger VL. Myocardial Infarction and Sudden Cardiac Death in Olmsted County, Minnesota, Before and After Smoke- Free Workplace Laws. Arch Intern Med Oct 29:1-7. PubMed PMID: MFMER slide-23

25 Community Snapshot: Top 10 Reasons for Doctors Visits Skin ailments, joint disorders and back pain are the most common reasons for visits in Olmsted County. Surprisingly, the most prevalent nonacute conditions in our community were not chronic conditions related to aging, such as diabetes and heart disease, but rather conditions that affect both genders and all age groups. - Study author Jennifer St. Sauver, Ph.D MFMER slide-24

26 Anticipatory Guidance Reduces ED Visits for Child Ear Pain At the 15-month well child visit Nurses provided standardized education around at-home control of ear pain (PPT) for parents to teach how to identify ear pain to relieve ear pain to recognize more serious illness requiring medical attention as well as providing Dosing instructions for generic analgesic ear drops. Impact: This intervention empowered parents to control ear pain better in their child and significantly decreased costly emergency room visits. Shared this safe, costeffective practice with community partners MFMER slide-25

27 SE Minnesota Beacon Technology to Support Population Health Top five pieces of advice/words of wisdom for other communities pursuing this work Develop Clear Usage Criteria Up Front No inter agency quality comparisons Find Ways to Include Non Traditional Providers Emphasize Community of Practice Leverage Local Assessment Data to Drive Initiatives Build and Maintain Credible Use Cases 26

28 Legal Considerations Business Associate Agreements between Between or among Beacon participants Beacon consortium and data repository Privacy Compliance: Health Insurance Portability and Accountability Act (HIPAA) Family Educational Rights and Privacy Act (FERPA) Public Health Agency State Data Practices Act (DPA) Consent & Authorization Compliance: Minnesota Standard Consent Form to Release Health Information Minnesota Research Authorization statute Federal protection of human subject research regulations Regional Exemption Obtained for State Certificate of Authority: Health Information Exchange, Health Data Intermediary, Record locator service

29 28

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