Extracting Value from Secondary Uses of Electronic Health Data

Transcription

1 Extracting Value from Secondary Uses of Electronic Health Data The Regenstrief Institute, Indianapolis Indiana Thomas S. Inui, ScM, MD President and CEO, Regenstrief Institute Associate Dean for Health Care Research, Indiana University School of Medicine 2009 Regenstrief Institute, Inc.

2 *

3

4 Indianapolis MSA, Indiana 1.7 million population base 553 square miles 12th largest city in U.S.A. Indiana Health Information Exchange Home to Indiana s only medical school IUSM State Department of Health and Marion County Health Department Referral center for entire state (approx 6.5 million)

5 RI IUSM IHIE

6 Regenstrief Institute An internationally recognized informatics and healthcare research organization, founded in 1969 Mission Statement: Advancing the health of the public through research and development. Medical Informatics: Pioneering health information solutions through research, application, evaluation. The Institute employs approximately 145 staff and 49 investigators (faculty members of Indiana University) NLM- and VA-funded Medical Informatics Training Programs

7 Regenstrief Institute, Inc., its Three Programs, and their Directors Regenstrief Institute, Inc. Inui: President and CEO Medical Informatics Director: Overhage Health Services Research Director: Doebbeling Geriatrics (IUCAR) Director: Callahan

8 Indiana Univ. School of Medicine Regenstrief Foundation RI Board of Directors Regenstrief Institute, Inc. Medical Informatics Health Services Research Geriatrics (IUCAR)

9 Trends in Research Funding by Program (Revised to include new awards as of November 14, 2008) Regenstrief Institute and Regenstrief Investigators Total funded dollars (in millions) Renovations & Rent Estimated Indirect Costs Health Services Research Biostatistics Center on Aging Editorship Informatics Fellowship Data management Core infrastructure Fiscal year

10 RI s Medical Informatics In the Beginning 1. Solve the logistic problems of paper records Always available, well organized and legible 2. Relieve MDs of clinical bookkeeping work Decision support 3. Unlock the research potential of the medical record room 4. Culture of re-use Develop foundations then layer Design components with the intent to re-use 5. Commitment to standardization

11 RI Has Lead the Industry in Standards Development and Use In 1984, a Regenstrief investigator led an effort that culminated in 1988 with the first clinical message standard. That work was carried into HL7 and today, virtually all clinical system vendors support HL7, and most North American, European, and Pacific Rim health care institutions use the HL7 standard for electronic data interchange in health care. HL7 is the primary clinical messages standard adopted by the Department of Health and Human Services for use in U.S. health care and public health operations.

12 LOINC Core of Clinical Data Collection Regenstrief /IU investigators initiated the development of the Logical Observation Identifier Names and Codes (LOINC ) database that now contains 51,000 standardized codes and names for clinical observations. LOINC enables the electronic transmission of clinical data from laboratories to hospitals, physicians offices and payers for clinical care and management purposes.

13 The Regenstrief Technical Landscape Data Management Data Access & Use Hospital Payers Hospitals Results delivery Secure document transfer Shared EMR Credentialing Eligibility checking Labs Health Information Exchange Physicians Negotiated Access Labs Results delivery Secure document transfer Shared EMR CPOE Credentialing Eligibility checking Results delivery Data Repository Network Applications Outpatient RX Public Health Surveillance Reportable conditions Results delivery Payer Secure document transfer Physician Office Ambulatory Centers Public Health Researchers De-identified, longitudinal clinical data

14 Key Value: Structured Data in RI Data management Data access and use Hospital Payers Hospitals Results delivery Secure document transfer Shared EMR Credentialing Eligibility checking Labs Health Information Exchange Physicians Results delivery Secure document transfer Shared EMR CPOE Credentialing Eligibility checking Data repository Network Server applications Labs Results delivery Outpatient RX Public health Surveillance Reportable conditions Results delivery Payer Payer Secure document transfer Physician office Ambulatory centers Public health Researchers De-identified, longitudinal clinical data

15 The Indiana Network for Patient Care The Indianapolis Network for Patient Care: An operational communitywide secure data exchange

16 INPC = RI s Clinical Data Repository Initiated in 1993 to demonstrate the feasibility and benefit of a community-wide electronic medical record system in patient care.

17 INPC The Early Years 1996: Wishard data to 3 EDs, no data sharing Demonstrated lowering of health care costs 1997: INPC Management Committee formed by Clarian, Community, St. Francis, St. Vincent, Wishard, IUMG-PC, Regenstrief Institute Central repository with data silos for each institution Agreed to share 50 common tests, limited visit data Global access rules established Printed abstracts to 11 participating EDs On-line access to INPC Careweb from all EDs

18 INPC Continued 1998: Communicable disease reporting to state and county public health 1999: Began sharing additional data Request all data that can be sent electronically 2004: PHESS project incorporated Currently 76 hospitals send ED data to us for ISDH 2006: MRSA alerts for inpatient admissions 2008: Evansville Hospitals joining INPC Continually adding new members

19 INPC Data Providers Indianapolis Medical/Surgical hospitals Physician offices Community health centers Homeless care network Public school clinics State and county public health departments National laboratories Pharmacies Pharmacy benefit managers

20 Classes of Data Shared by all Institutions ED and outpatient visits Hospital discharges (dx, procedures) Inpatient laboratory results Outpatient laboratory results Immunizations Discharge summaries/admissions summaries Operative notes Radiology reports Surgical pathology reports Inpatient medications Tumor registry data

21 INPC Data Volumes January million registration events 60 million orders 900 million coded results 20 million dictated reports 8.8 million radiology reports Hundreds of millions prescriptions 750,000 EKG tracings 45 million radiology images

22 Clinical Information Flow Hospital Registration HL7 ADT message Hospital Interface Engine (Routing) Hospital Firewall (Encryption) Network Connection Repository Stored in clinical repository Message Processor Message Listener Firewall (Decryption)

23 Clinical Data Standards Messages HL7 messages DICOM messages NCPDP messages Content LOINC for laboratory results content CPT-4 for procedures content ICD-9 for diagnoses content RxNorm for medications content SNOMED for microbiology content Patient: John Doe MRN: Diagnosis: WBC: 14,000/cm 3

24 Example #1: Data Reuse in INPC Public Health Surveillance and Reporting Data management Data access and use Hospital Payers Hospitals Results delivery Secure document transfer Shared EMR Credentialing Eligibility checking Labs Health Information Exchange Physicians Results delivery Secure document transfer Shared EMR CPOE Credentialing Eligibility checking Data repository Network Server applications Labs Results delivery Outpatient RX Public health Surveillance Reportable conditions Results delivery Payer Payer Secure document transfer Physician office Ambulatory centers Public health Researchers De-identified, longitudinal clinical data

25 Indiana Public Health/HIE Activity Statewide disease surveillance Electronic Laboratory Reporting of Notifiable Conditions Public Health Clinical Messaging Lead Reporting Newborn Screening

26 Statewide Public Health Surveillance System (PHESS) Indiana law requires hospitals with emergency departments to electronically provide a certain core set of data elements to ISDH on a real-time or near real-time basis, such as chief complaint ISDH engaged Regenstrief to develop and manage the interfaces with all the hospitals in the state to support the PHESS project

27 Current PHESS Hospitals (n=76) > 6,500 visits per day ~ 15 MB data per day

28 Surveillance Information Flow Hospital ED Registration HL7 ADT message Hospital Interface Engine (Routing) Hospital Firewall (Encryption) Network Connection Batched, delivered to ISDH every 3 hours Message Processor Message Listener Firewall (Decryption)

29 No Change in Workflow Since PHESS requires information that is already being collected by the registration system, there is no change in work flow, (unless chief complaint is not currently captured) The only upfront work involved is setting up connectivity and an HL7 interface. On average it takes approximately 11 hours of a network engineer and interface programmer s time for this project Record go live time set on 3/6/2006 under 3 hrs

30 Public Health Alerting

31 Public Health Alert: GI Event

32 GI Syndrome Outbreak

33 Visualization: Public Health Electronic Surveillance System (PHESS)

34

35 Clinical Messaging/Public Health Messaging

36 Results Delivery An Illustration

37

38 Bi-directional Communication: Case Reporting Forms

39 Reporting Form

40 Example 2: Clinical Test Results Delivery Data management Data access and use Hospital Payers Hospitals Results delivery Secure document transfer Shared EMR Credentialing Eligibility checking Labs Health Information Exchange Physicians Results delivery Secure document transfer Shared EMR CPOE Credentialing Eligibility checking Data repository Network Server applications Labs Results delivery Outpatient RX Public health Surveillance Reportable conditions Results delivery Payer Payer Secure document transfer Physician office Ambulatory centers Public health Researchers De-identified, longitudinal clinical data

41 Results Delivery An Illustration

42

43 Example 3: Quality Profiling Data management Data access and use Hospital Payers Hospitals Results delivery Secure document transfer Shared EMR Credentialing Eligibility checking Labs Health Information Exchange Physicians Results delivery Secure document transfer Shared EMR CPOE Credentialing Eligibility checking Data repository Network Server applications Labs Results delivery Outpatient RX Public health Surveillance Reportable conditions Results delivery Payer Payer Secure document transfer Physician office Ambulatory centers Public health Researchers De-identified, longitudinal clinical data

44 RI IHIE Partnership The Indiana Health Information Exchange (IHIE) was formed in February 2004 to extend the HIE infrastructure and intellectual property developed and built by the Regenstrief Institute, Inc. IHIE works hand-in-hand with Regenstrief to create sustainable business models and provide commercial levels of support for the Institute s technologies in the marketplace. Whereas Regenstrief s mission is research and development, IHIE s mission is focused on customer services and the expansion of HIE throughout Indiana and beyond. First initiative Electronic test results delivery.

45 IHIE Quality Health First Program Dr. Jim Smith has been practicing Internal Medicine for nearly 20 years. He has been considering installing an EMR in his practice, but has yet to do so. Dr. Smith knows that he takes care of about 1,700 patients, but he isn t sure of the exact figure. He also doesn t know which patients have chronic conditions or other diseases that require regular follow-up. 45

46 Quality First Case Scenario The IHIE physician liaison provided Dr. Smith with a report that summarized how his aggregate patient population was controlled in specific chronic conditions, or measures, that are an indicator of health and wellness. Insurer Wellpoint sponsors P4P program Quality Health First provides tools: Provider Performance Patient Care Sheets with Alerts & Reminders 46

47 Quality First Program Enrollment Indianapolis MSA 1.7M population 3,000 active physicians PCPs currently participating 47

48 Example 4: Prescribing Alerts Regenstrief Repository and Data management Data access and use Hospital Payers Hospitals Results delivery Secure document transfer Shared EMR Credentialing Eligibility checking Labs Health Information Exchange Physicians Results delivery Secure document transfer Shared EMR CPOE Credentialing Eligibility checking Data repository Network Server applications Labs Results delivery Outpatient RX Public health Surveillance Reportable conditions Results delivery Payer Payer Secure document transfer Physician office Ambulatory centers Public health Researchers De-identified, longitudinal clinical data

49 P a t i e n t P r o f i l e : M a r y P a l t r o w Mrs. Mary Paltrow 57 year old female recently moved to Indianapolis previously lived in Ohio Where are her medical records? HealthBridge (HIE in Cincinnati) HealthLINC (HIE in Bloomington) Indivo Personal Health Record (PHR) RxHub (Commercial Pharmacy Benefit Manager)

50 Medication Alert! Dr. Inui learns that Mrs. Paltrow has a Documented allergy to drug A and switches to drug B. Clinic Registration INPC NHIN Gateway Aggregator!!! Gopher Prescribing

51 Extracting Value from Secondary Uses of Electronic Health Data: Regenstrief s Lessons Learned Personal health data have value beyond the individual encounter. If standardized and linked, they can improve patient care safety, quality, and cost-effectiveness. The same data can inform public health and research. The major challenges in this data exchange are several: Cost Minimizing incremental effort for data entry Interoperable technical platforms Data standards Preserving/deserving trust