LEVERAGING WEB-BASED MODULAR TECHNOLOGIES TO ENHANCE MEANINGFUL USE OF EHRs
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1 LEVERAGING WEB-BASED MODULAR TECHNOLOGIES TO ENHANCE MEANINGFUL USE OF EHRs Jatinder R. Palta, PhD, Professor and Chief of Physics, Department of Radiation Oncology University offlorida Shands Cancer Center, Gainesville, FL IHE-ROTask Force Co-Chair Martin Pellinat, CEO VisionTree Software September 9, 2010
2 Topics for Discussion Applying new modular health information technology to current workflow to measure outcomes in cancer patients in an academic medical center The use of modular technologies in other Meaningful Use data sets Discuss the perceive and documented benefits and physician adoption rates associated with patient-centered data collection and communication Coordinating care team responses with meaningful analysis of outcomes data
3 Radiotherapy Workflow / Process Overview Multidisciplinary review Radiation oncologists, medical oncologists, surgeons, pathologists, radiologists review imaging, lab reports, and medical history Patient immobilization and imaging for radiation treatment planning Treatment target and normal tissue delineation Treatment planning Patient setup for treatment and plan verification Radiation treatment On treatment review Post treatment follow-up
4 LiteBox LiteBox Simplified Radiotherapy Process TPS CT SIM RT-EMR MAGN ETOM CT LINAC
5 LiteBox LiteBox LiteBox LiteBox Detailed Radiotherapy Process CT MR Archive Portal Imaging MAGN ETOM MAGN ETOM DB HIS/EMR Image Image All Non DICOM Image Image SS, Plan, Multi Image SS, Plan, Dose, Multi Image SS, Plan, Dose, Multi Image Record Plan Simulator Virtual SIM. TPS Review Linac Station Typical RT dataset/patient includes DICOM Images, Plan, and Dose (300 M byte - 4 G byte)
6 Radiation Oncology Patient Portal: Key Use Case The Radiation Oncology Patient Portal (ROPP) provides a patient with authenticated and authorized access to a set of patient specific reports and alerts for Meaningful Use as required by the ARRA HITECH Act. Patient Portal Attributes: Secure Patient Login - patient can login to the portal from a computer outside the enterprise. PRO Completion - Patients can complete QoL assessments in their secure portal. Assessments can be delivered at specified time points (i.e. pre-treatment, 3 month, 6 month, 12 month, etc). Reminders & Messaging triggers set by the provider will send /sms text alerts and reminders to the patient and medical team Registration / Health History - Patients can provide registration and health history information. An integrated EHR and integrated Medical Team & Patient Portal system enables: Pharmacy, Lab Results, Procedure Eligibility - data access. Treatment Summary and Relevant Education Materials - meeting ARRA requirements. Clinical Trials - Visibility of appropriate ongoing clinical trials, clinical trial matching. Connectivity to remote/home monitoring systems. Reminders, messages and forms - triggered based on data values. Data analysis and trends on medical team side, patient-level reporting.
7 Radiation Oncology Patient Portal: Use Cases / Meaningful Use Criteria ARRA HITECH: Act Core Measure (15 Must Be Met)* ROPP ARRA HITECH: Act Menu Measure (7 of 12 Must Be Met)* ROPP 1. Record Patient Demographics 2. Record Vital Signs & Chart Changes 3. Maintain Up-To-Date Problem List & Active Diagnosis 4. Maintain Active Medication List 5. Maintain Active Allergy Medication List 6. Record smoking status for patients 13+ yrs old 7. Provide Clinical Summary / Hosp. Discharge Instructions 8. On Request, Provide ephr 9. Generate & Transmit eprescriptions 10. Computer Provided Order Entry (CPOE) for Medications 11. Implement Drug/Allergy Interaction Check 12. Implement Prov./Pt. Exchange of Clinical Information 13. Implement & Track One Clinical Decision Support Rule 14. Implement System to Protect Privacy & Security of PHI 15. Report Clinical Quality Measures to CMS / State 1. Implement Drug Formulary Check 2. Incorporate Lab Results in Structure Data Format 3. List Patients by Condition for Quality Improvement, Research 4. Identify Patient-Specific Resources and Provide to Patients 5. Perform Medication Reconciliation Between Care Settings 6. Provide Summary of Care Record for Patients Referred 7. Submit Electronic Immunization Data to Registries 8. Submit esyndromic Surveillance Data to Public Health Agencies 9. For Hospitals Record Advance Directives 10. For Hospitals, Submit elab Data to Public Health Registries 11. Send Reminders to Patients for Preventive/ Follow-Up Care 12. Provide Patients with Timely ephr Access * Highlighted Measures represent those that can benefit from connectivity with or use of a ROPP. **ARRA HITECH Act Meaningful Use Core and Menu Measures can be found at:
8 Patient Portal / Interoperability for Collecting & Aggregating Outcomes Data PQI (PAAROT) OCER EHR / PHR (Health Vault, Google Health...) PQRI (Compliance and Quality Reports) National Radiation Oncology Registry (NROR)* (Disease Site-specific CRO and PRO Data Elements for Each Patient) Web-based Data Entry / Reporting Template URL Redirect Query/Retrieve Data element Data element ROPP can facilitate the development of a National Radiation Oncology Registry (NROR). ROPP use case will allow abstraction of NROR data elements from RT_EMR, patent/ clinician portal and generation of quality reports. ROPP use case is an essential step to achieve Meaningful Use of RT-EMR. RT-PACS RT-EMR (MOSAIQ, ARIA...) Patient Portal (HRQoL) Data elements independently validated by clinical team Data element Clinician Portal (CRO) *Courtesy IEEE Computer Society; August, 2010; Palta, Frouhar, Zlotecki
9 Layered Patient Portals in Care Continuum Radiation Oncology Patient Portal facilitates longitudinal collection of PRO data (HRQoL data) Pre-treatment Patient On-treatment Portal Patient (Education material, facility info., Post-treatment Portal Patient (Appointments, posting Medications, Portal Medical test results, Alerts & Intake data forms, medical record (HRQoL reminders, instruments Adverse for reaction longitudinal reporting, studies, etc.) Toxicity reporting; Rule and Role-based communication and feedback) Layered Patient Portals ( Temporal) Patient-level data may be exchanged between patient, provided coordinated care team and PHR (e.g. HealthVault, Google Health) *Courtesy IEEE Computer Society; August, 2010; Palta, Frouhar, Zlotecki
10 Radiotherapy Data Abstraction for Outcome Studies and EHR PQI (PAAROT) OCER EHR / PHR (Health Vault, Google Health...) PQRI (Compliance and Quality Reports) RT Data profile (Disease Site-specific CRO and PRO Data Elements for Each Patient) Web-based Data Entry / Reporting Template URL Redirect Query/Retrieve Data element Data element RT-PACS RT-EMR (MOSAIQ, ARIA...) Patient Portal (HRQoL) Data elements independently validated by clinical team Data element Clinician Portal (CRO) *Courtesy IEEE Computer Society; August, 2010; Palta, Frouhar, Zlotecki
11 NetSys Image Reader MAGN ETOM Imaging Device Film Scanner Clinic PC NetSys Images RCET Infrastructure Web Based Upload/Download Tool (3) (2) Web Based Electronic Folder & Rapid Review Tools Reviewer PC SOANS NetSys NetSys DICOM-RT Server NetSys RTOG Reader DICOM DICOM-RT RTOG Visualize (2D 3D), DVH, Iso-dose, Cutplane, etc. Case info Review Modify Structures Annotate Etc. External Database (1) RCET Database RCET Server Treatment Planning
12 Performs Auto Archiving of Submitted Case Data Allows Fast Multi User Internet Access Data Authoring and Versioning (DAV) control keeps track of authors and changes to the data The database is designed to overcome network bandwidth limitations and allow future growth Palta:04/06/05 12
13 This component is best understood in analogy with Picture Archiving Computerized Systems (PACS) The SOANS deals with any data object encountered in radiation therapy The SOANS is protocol centric in data organization The SOANS supports secure encrypted data transfer across a wide area network (WAN) The SOANS provides the interface between the database and the client applications The SOANS can be queried for data objects based on any of their database attributes (similar to PACS) Palta:04/06/05 13
14 Allows Preparation and Submission of Radiotherapy and Diagnostic Imaging Data DICOM Server and Image Interpreter imports Performs Anonymization of Patient Data Views Are Set for Rapid Web Review A thick client application Palta:04/06/05 14
15 Allows review of Data Prepared with the NetSys PC Client: JPEG snapshots of the originals Viewing of CT, MR, Port Film, DRR, DVH, scanned images, and Radiotherapy Plan Accessible Seconds After Submission Secure WAN Multi User Access Palta:04/06/05 A thin client application 15
16 Rapid Image Viewer Displays diagnostic and treatment verification images Images are organized in an electronic folder 16
17 Hospital EIS Interface Business Tier Web Tier Patient Portal Data Interchange Standards & Systems Enterprise Info System (EIS) HISP Servers Client Tier (Browser or Application) HIS HL7 In/Outbound HTTPS Radiation Oncologist Portal RT-EMR HL7 In/Outbound HTTPS Patient Portal RT-PACS DICOM-RT Push HTTPS Clinical Research Portal Tumor Registry HL-7 Push HTTPS PAAROT MOC National Quality Benchmark CCR / CCD PHR Data Interchange RO Database Data exchange and reporting to data registries to meet ARRA HITECH Act Stage 1 and forthcoming Stage 2 & 3 Requirements. Monitoring Systems (Hypertension, Glucose) w/ API Open ID / Oauth Single Sign-On
18 ROPP: Roles & Quality Alerts Based on a user s role (i.e. physician, researcher, nurse, or other medical team member will be able to: Patient Account & Consent Management - create, access, update, send/receive messages. Update Patient Portal Data - schedule modifications, medications / refills based on patient request. Set patient specific alerts Read / Respond to patient specific alerts Send / Receive Quality Alerts - triggered by roles, metrics, tasks and form completion & outcomes data collection, toxicity grades, lab results & related adverse events and messaging are necessary for quality care and treatment. Generate Quality Metrics Reports - including identifying QA performed on behalf of patient, e.g. IMRT QA or lack thereof and real-time national quality benchmark data.
19 Radiation Oncology & Coordinated Care Team Patient Workflow
20 Patient Portal Features & Data Exchange 1) Patient logs on to their secure, web portal. 2) Completes CCR, outcomes assessments and forms at specific time points. 3) Receives reminders for forms completion, appointments. 4) Secure 2-way messaging for appt / refill requests & needs. 5) Ability to view/store labs, imaging. 6) Receive Treatment Summary (CCR/CCD) and Treatment Pathway follow-up reminders / educational material.
21 Data Cascades Between EMR / VTOC Forms
22 Roles & Rules-Based Alerts Set / Send Alerts & Triggers from Discreet Form Data
23 Includes Form Sharing Library & Best Practice Templates Radiation Oncology Clinical / Disease Specific Templates
24 Data Cascades Between EMR / VTOC Forms Data cascades between EMR and VTOC portal system for form for auto-completion and reporting, including: VTOC forms data from Registration, H&P, Toxicity QoL forms Roles-based forms completion. Rules-based notification
25 Mapping / Crosswalk of VTOC forms & files Auto-export to EMR via HL7 message w/ Document Type Scheduled Data Export to EMR
26 Radiation Oncology Quality Reporting by Disease Type EMR Connectivity for Aggregate Quality Measures Dashboard with National Benchmark Data &Reporting/Filters on a Department Level
27 Patient-Level & Aggregate Reporting Patient Lists by Diagnosis / Self-Generated Reporting Queries for Clinical & QoL data. Demographic, Procedure & Diagnosis Data Filters w/ Excel export.
28 UF Shands & UFPTI VTOC Results & Other Experiences 5,000+ Patients - with OTV and long-term QoL data including: IPSS, EPIC, IIEF 1,000+ patients actively using patient portal o 80% online participation o 90%+ want to keep using it long-term o Average age: 60+ yrs old VTOC Cancer Center sites nationally include: o UF Shands / UFPTI o UPENN o ProCure Treatment Centers o Henry Ford o UCSF o UCLA / Athena Breast Cancer Registry o ASTRO PAAROT National MOC Quality Reporting Program Other Results Include: o 6 Peer Reviewed Abstracts o 30% post-treatment quality of life o 30% missed canceled o RTOG 0828 (20 Sites) Measuring: Form Completion/Quality, Patient Compliance & Alerts
29 Patient Portal for Meaningful Use Clinical Team / Patient Paperless Workflow - Registration, H&P, PROs, ecrfs, CCR/CCD delivered to patient for Treatment Summary PRO/QoLs, OTV, H&P, CCR/CCD Treatment Summary Alerting & Reporting - Layer on top of EMR & Practice Management Systems for collecting QoL and toxicity data sent via /sms text as actionable triggers Quality, A/E Alerts, Msg, Case Conferencing Integration - Data Extraction & Mapping - HL7, ML, CSV Connectivity Web & Mobile Access - Providers, Patients, Registry Admin Reporting, Real-Time Metrics Messaging, Compliance & Education - Clinical templates deliver and collect information Large Scale Data Capture & Analytics - Community connectivity
30 ROPP: Overarching Data Exchange NHIN Direct: Point-to-Point Patient-Level Data Exchange Model That may be used for the ROPP * Courtesy of Office of the National Coordinator for HIT (ONC):
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