Fatal Flaws: Introducing Risk by Substituting EMRs for Public Health Information Systems

Transcription

1 Fatal Flaws: Introducing Risk by Substituting EMRs for Public Health Information Systems ehealth 205 Margie Kennedy, PhD, RN, CPHIMS-CA, PMP, P2P Maureen Perrin, MSc, CPHIMS-CA, CAPM

2 Objectives. Distinguish between Electronic Medical Records (EMRs) and Public Health Information Systems (PHIS) 2. Define the types of information requirements and outputs generated from EMRs and PHIS 3. Explore the impact of using EMR solutions as fully functional PHIS 4. Present recommendations for pragmatically assessing public health solution requirements 2

3 Healthcare System EMR Individual Primary Care, Tertiary Care Community Contacts & Exposure Tracing PHIS Population Surveillance, Aggregation, Trends 3 3

4 4 Blurring Lines

5 What is public health? Our public health focus: communicable disease and immunization 5 Source:

6 Informing the Debate Qualitative comparative analysis of current literature Online survey 6

7 DISTINGUISHING BETWEEN EMRS ANDPHIS 7

8 Electronic Medical Record Record for a single individual at the point of care Characterized by problem identification, patient/provider-level data and decision support Reflective of individuals seeking care Value for improving outcomes, improving access to data, and reducing error Primary care setting Physician office Nurse led clinics 8

9 Electronic Medical Record 9 Doyle, 203

10 Typical EMR Functionality (Kukafka et al, 2007) Identify and maintain patient record Manage patient demographics Manage problem list Manage medication list Manage allergy and adverse reaction list Manage patient history Summarize health record Manage clinical documents and notes Capture external clinical documents Generate and record patient-specific instructions Order medications Order diagnostic tests Manage order sets Manage results Manage consents and authorizations Manage patient advance directives Support for standard care plans, guidelines, and protocols Capture variances from standard care plans, guidelines and protocols Support for drug interactions 0

11 EMR: Logical Model Client Client Identifier Assigning Authority Cod Client Identifier Client Identifier Type Code Birth Date Administrative Gender Code Residence Postal Code Provider Provider Identifier Assigning Authority Cod Provider Identifier Provide Identifier Type Code Provider Role Type Code Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0 Logical Model January, 204 Service Delivery Location Service Delivery Location Identifie Postal Code Health Service Event Provider Client Status Client Status Code Encounter Encounter Date Request Date Reason Code Contact Mode Code Observation Intervention Intervention Code Intervention Date Lab Request Test Ordered Code Test Ordered Date Diagnostic Imaging Request Test Ordered Code Test Ordered Date Referral Request Referral Requested Date Referral Service Code Medication Prescribed Medication Code Prescribed Date Immunization Vaccine Code Vaccine Administered Date Health Concern Health Concern Code Onset Start Date Clinical Assessment Ind Cod Social Behaviour Social Behaviour Code Measured Observation Observation Type Code Observation Value Observation Unit of Measure Lab Result Test Result Code Test Performed Date Test Result Value Text Test Result Unit of Measur Diagnostic Imaging Result Test Result Code Test Performed Date Referral Result Service Result Code Referral Occurred Date

12 Public Health Information System Focus is on prevention, protection, promotion at population level Define population based on geography or other demographic factors (e.g. gender, race, age, disease status) Used by public health Monitor trends and detect events Includes contacts (non-cases) and non-humans Manage of cohorts during outbreaks Focus on reporting for action 2

13 Public Health Information System 3 Source:

14 Typical PHIS CD Functionality Condition Reporting Event Identification and Validation Case Investigation Contact Tracing Case/Contact Specific Intervention Event/ Outbreak Management Public Health Alerts 4 Source: Public Health Informatics Institute. (203). Electronic Disease Surveillance System (EDSS) Vendor Analysis,. Decatur, GA: Public Health Informatics Institute

15 PHIS: Logical Model PARTY PARTY RELATIONSHIP Party Identifier : SET<II> Party Relationship Date Time Range : IVL<TS> Party Relationship Type Code : CV INDIVIDUAL Birth Date : TS Death Date : TS Sex Code : CV 0.. MATERIAL RESPONSIBILITY Responsibility Type Code : CV Responsibility Date Time Range : IVL<TS> Material Identifier : II ACTOR PARTICIPATION Actor Type Code : CV Actor Time Range : IVL<TS> TARGET PARTICIPATION Target Type Code : CV Target Time Range : IVL<TS> Target Awareness Code : CV HEALTH-RELATED ACTIVITY Activity Identifier : SET<II> Activity Mood Code : CV Activity Type Code : CV Activity Descriptive Text : FTX Activity Status Code : CV Activity Date Time : GTS Activity Critical Date Time : GTS Activity Method Code : CV Subject Site Code : CV Interpretation Code : CV Confidentiality Code : CV Maximum Repetition Number : INT Priority Code : CV ACTIVITY RELATIONSHIP Activity Relationship Type Code : CV Activity Relationship Date Time Range : IVL<TS> PERSON Ethnicity Code : CV Race Code : SET<CV> Occupation Code : CV Person Name : SET<PN> NON PERSON LIVING ORGANISM Species Name : CV Organism Name : ST ORGANIZATION Organization Name : SET<ON> FORMAL ORGANIZATION Industry Code : CV INFORMAL ORGANIZATION Group Type Code : CV LOCATION RELATIONSHIP Location Relationship Type Code : CV Location Relationship Date Time Range : IVL<TS> MATERIAL RELATIONSHIP Material Relationship Type Code : CV Material Relationship Date Time Range : IVL<TS> PARTY LOCATION PARTICIPATION Participation Date Time Range : IVL<TS> Participation Type Code : CV Current Status Code : CV Current Status Effective Date : TS LOCATION Location Identifier : SET<II> Location Setting Code : CV Location Type Code : CV Location Status Code : CV Current Status Effective Date : TS Location Narrative Text : FTX 0.. MATERIAL Material Identifier : SET<II> Material Type Code : CV Material Description : FTX Material Date Time Range : IVL<TS> Handling Code : CV Danger Code : CV Material Quantity : PQ Material Name : ST SPECIMEN Source Site Code : CV MATERIAL LOCATION PARTICIPATION Participation Date Time Range : IVL<TS> Participation Type Code : CV 0.. OBSERVATION Observation Value : ANY Derivation Expression Text : ST CA SE Confirmation Method Code : CV Detection Method Code : CV Transmission Mode Code : CV Disease Imported Code : CV Etiologic Status Code : CV Classification Status Code : CV OUTBREAK Outbreak Extent Code : CV Outbreak Peak Date : TS Outbreak Time Range : IVL<TS> INTERVE NTION Intervention Reason Code Intervention Form Code : CV Intervention Route Code : CV Intervention Quantity : PQ Strength Quantity : PQ Rate Quantity : PQ REFERRAL Referral Reason Text : FTX Referral Description : FTX NOTIFICATION POSTAL LOCATION Street Address Text : AD Address Directions Text : FTX TELECOMMUNICATION LOCATION Personal Identification Number : ST Time Zone Text : ST Electronic Address Text : TEL PHYSICAL LOCATION Latitude Quantity : ST Longitude Quantity : ST Location Name : ST Property Location Text : FTX Notification Reason Code : CV 5 Source:

16 Distinctions between EMR and PHIS EMR Purpose Support primary care, health delivery service Family physician Nurse-led clinics Scope Treating illness of an individual Functionality Clinical Assessment Diagnostics (Labs, DI, etc.) Pharmacological interventions Limited or ongoing medication Treatments (Physio, OT, other regimens) Follow up Key outcomes: Administrative (scheduling, billing, etc.) Clinical management Referrals/specialist PHIS Purpose Support health prevention/control and promotion at population level Clinical Surveillance Scope Monitoring, detection, prevention in a population Functionality: Managing immunizations Identifying, investigating and managing cases and contacts of communicable disease Supporting surveillance, investigation, monitoring, management, analysis and reporting of communicable disease outbreaks Notifying public health professionals so information about critical events and emergencies can be shared quickly Managing public health work processes Key outcomes: Reporting Health system response Targeted health interventions Policy and regulation development 6

17 Temptation to Substitute EMR for a PHIS Potential to stretch functionality in the presence of fiscal constraint Can t afford both EMR & PHIS McGyver an expanded functionality Higher expectations for collaboration between sectors Promise of real time bio-surveillance EMR can document immunizations Unstructured notes allows for inclusion of data not included in typical EMR scope Assumptions that data is easily interoperable and useful for public health Seduced by the promise of big data Can embed algorithms to monitor trends 7 Zinszer et al., 203; Reeder et al., 203; Klompas et al., 202

18 Introducing Risk Through Substitution Critical Gaps EMR focus is illness based vs PHIS focus on health & prevention Different EHR models between vendors Often do not include psychosocial, psychological, behavioral, or environmental factors relevant to public health (Vodel, 204; Tomines et al, 203) Surveillance in EMRs is largely on chronic diseases (diabetes, etc.) Only touch those individuals that seek medical care Historical reluctance to share data Data quality Limited by standards, consistency in codification, GIGO, limited to geographical area (Vodel, 204; French, 204) May be fragmented among variable providers Data may be too noisy and poorly controlled for aggregation purposes (Kakafka et al, 2007) Potential for double counting if recorded by multiple providers Surveillance bias & Overdiagnosis (Eur Jnl of Public Health, 203) 8

19 THE CANADIAN EXPERIENCE 9

20 Characteristics of Respondents 4 completed surveys representing 9/3 jurisdictions 46% represented provincial public health Composition Managers Nurses Physicians Over half of respondents have more than years of experience in public health 20

21 Survey Responses Types of Information Systems for Public Health Paper records, 9 EMR, PHIS, 9 Hybrid environment implies transition Gaps in PHIS experience by 40% of respondents Custom system, 8 2

22 22 RECOMMENDATIONS

23 Our Collective Obligation Era of increased complexity of disease and care and global population health crises Ensure that the core requirements of healthcare delivery and prevention/promotion are supported with appropriate resources prepared HCP, and the required information management tools to deliver care and prevention to the Canadian population. 23

24 Conclusions Lines are increasingly blurred between community-based care and public health Where and how does it make sense to align from an informatics perspective? The architectural and logic models informing both EMRs and PHIS are fundamentally unique Lack interoperability and comprehensive overlap The opportunistic use of EMRs as a substitute for a fully functional electronic public health information management solution is at it core, an unacceptable risk inducing attempt to cost save at the peril of our populations 24

25 A Path Forward Make decisions being fully informed of the distinction in scope and functionality between EMRs and PHIS Need policies to: guide development of systems that share defined data with PH (Zinszer et al, 203) Reuse current data and capture new relevant data (Kukafka et al, 2007) Enable EMRs to generate automated extracts with algorithms sensitive to public health to flag relevant cases Klompas et al, 202; Zheng et al, 204, Vogel,

26 Other Options Public Health Surveillance and Informatics Program Office (PHSIPO) by CDC as a centralized point of leadership MDPHnet Created by Harvard Distributed network to share data from EMR PopMedNet ESPnet Voluntary subscription 26

27 27 Art of the Possible

28 Moving Forward Sweet spot between EMRs and PHIS where there s a shared interest Fit for purpose is the over-riding principle Focus is on scope and interoperability EMR is reactive PHIS is proactive In the absence of declarative leadership, who guides selection decisions? 28

29 29 Long Game

30 30 DISCUSSION

31 Maureen Perrin, MSc, CPHIMS- CA, CAPM Senior Consultant and Epidemiologist Public Health Specialty Practice e: m: Margie Kennedy, PhD, RN, CPHIS- CA, PMP, PRINCE2 Practitioner Associate Managing Partner, Senior Consultant and Clinical SME Atlantic Branch e: m: Gevity Consulting Inc. All Rights Reserved. Any trademarks or service marks used are the property of their respective owners. Version: 0.93 ( ) Gevity Consulting Inc. # Water Street Vancouver BC V6B 5C6 Canada 3