Host Site: Denver Public Health Department, Epidemiology, Informatics, and Preparedness Location: Denver, CO Primary Mentor: Arthur Davidson, MD, MPH Director of Epidemiology, Informatics, and Preparedness, Denver Public Health Department Secondary Mentor: Emily McCormick, MPH Epidemiologist, Denver Public Health Department Fellow s Workplace Support: Interprofessional education and professional development are key areas of focus for Denver Public Health senior leadership with workforce development called out specifically in the department strategic and annual plan. The health department has a wide spectrum of health professionals all working collaboratively on strategic goals. DPH has decades of experience with a variety of training programs (medical and public health students, residents, fellows as well as CDC funded programs (PHAP, PHPS, APHIF, CSTE applied epidemiology), make this placement ideal for a dynamic, meaningful, and unique interprofessional educational experience. Collaborative practice and strengthened partnerships are common between public health and health care system/providers, and non-public health governmental agencies using innovative informatics best practices. The fellow will have ample opportunity for collaboration as a member of the Epidemiology, Informatics, and Preparedness Group working on cross-cutting projects that span public health, healthcare delivery and health services research. This group is managed by Art Davidson and includes a diverse team with immense knowledge about public health, clinical care and disease states, data access, quality and have relationships with important counterparts across Denver Health and the county. All colleagues will work with the fellow to cultivate knowledge, build capacity, and support collaboration and knowledge sharing. This group collaborates with all DPH programs and other health services research areas within Denver Health. Working on a team with strong knowledge base and analytic capability, the fellow will play a key role in building partnerships across public health, healthcare, and community base services providers. The proposed projects above were selected specifically for their cross cutting nature. DPH will work hard to expose the fellow to partner organizations prioritizing collaborative activities involving Denver Health components, neighboring local health departments, Denver Human Services, the state health department, Colorado Clinical Translational Sciences Institute at University of Colorado Denver, and local community partners. A modern networked health care organization is a major asset to informatics research and activities. Given our organizational structure and composition, DPH will provide the fellow with a more integrated (clinical and public health) data-driven environment than might be seen in most other communities. This training will prepare the fellow for what is expected to be common required informatics competencies in the years to come. Recent federal investments in EHR and health information exchange (between clinical and public health services) will support measurement of projected outcomes of the Affordable
Care Act. Our organizational structure will permit the fellow to benefit from institutional knowledge and service capabilities. DPH, as part of Denver Health, benefits from a comprehensive administrative structure that supports all operations. The fellow will attend a comprehensive enterprise wide orientation including gaining access to some of the most advanced technologies in the healthcare sector. Denver Health s ehealth Services will orient the fellow to public health, clinical, and administrative electronic applications through its desktop, server, database, network, security and web services teams. This department of more than 120 individuals makes sure all employees have a safe and secure networked environment capable of interacting with the local, regional and national partners. Denver Public Health (DPH) has been among the forerunners of innovation and public health informatics for nearly 3 decades. As part of a larger healthcare organization (Denver Health), tremendous enterprise opportunities have been leveraged often resulting in more coordinated informatics investments. From early electronics health record (EHR) efforts with optical mark recognition (1987) to the Davies Public Health Award (2009) for an EHR, HealthDoc, DPH has been exploring efficient methods to support personal and public health efforts. These ongoing efforts led to the National Association of County and City Health Officials (NACCHO) naming Denver Public Health as the 2013 Local Health Department of the Year for its use of innovative, technology-based approaches that promote the health and well-being of Denver residents (http://www.naccho.org/membership/winners.cfm). The fellow will benefit from vast informatics experience and knowledge present at DPH and Denver Health hospital and will be involved in projects and use tools that demonstrate how informatics can track and improve community health including the CHORDS distributed data network CVD registry work, clinical reporting tools developed to track utilization patterns (Microsoft Powerview and PowerPivot), custom chronic disease business intelligence tools, and an electronic QuitLine referral system embedded in the patient electronic health record. The fellow will be oriented to DPH and DH informatics tools at the onset of their fellowship and their fellowship activities. As required, fellow areas of focus may be amended or customized to include additional activities or projects interfacing with these informatics tools. The fellow will have access to an individual work space, common to the rest of the informatics group, computer with internet and broad intranet access, telephone, fax, and copier. When necessary, a laptop will be available for use by the fellow. Administrative support will be provided through DPH. Office productivity software (MS Office, Outlook, Internet Explorer, EndNote, Visio, and SAS) will be loaded on the standard machine, as for all PHIG members. The computer, resources, and technologic capacity offered at Denver Health exceed the standards set by CDC. The fellow will have access to any statistical packages necessary to meet the objectives of their assignment including but not limited to SAS, R, SPSS, STATA, SQL Server. Denver Public Health utilizes a distributed surveillance network that accesses electronic health record data across local health care providers through a federated query mechanism. The fellow will have access to this data as well. The fellow may access and utilize any data sets accessed or maintained by Denver Public Health to meet fellowship objectives including but not limited to Census, American Community Survey, Youth Risk Behavior Survey, Tobacco Attitudes and Believes Survey, Colorado Health Access Survey, and Colorado Electronic Disease Reporting System.
Community Engagement Partners: Colorado Clinical Translational Sciences Institute Colorado Regional Health Information Organization Denver Health Ambulatory Care Services (ACS) Project 1 Title: Denver Cardiovascular Disease Registry Project Description: Cardiovascular disease (CVD) and its attendant risk continue to cause substantial morbidity, mortality and healthcare costs in Colorado. If clinicians and public health practitioners are to make progress reducing CVD risk, they need readily available and easily interpretable information to monitor the problem and inform: 1) healthcare providers, 2) community groups, and 3) individual patients. In an effort to leverage healthcare investments in electronic health records to benefit and inform both clinical care and public health, Denver is developing a CVD Risk monitoring system to track trends, and outcomes of clinical- and community-based interventions. To date, 8 Colorado healthcare institutions have partnered to develop a distributed data network (DDN) to monitor key population and primary care indicators. The Colorado Health Observation Regional Data Service (CHORDS) is currently implementing and testing a distributed monitoring network that develops public health registries for tobacco use and body mass index (BMI). The monitoring system uses an integrated registry approach. At each healthcare provider site, data from the electronic health record are transferred to a standard data warehouse accessible by the public health agency over a distributed data network. Data are retrieved and aggregated across multiple healthcare providers to understand and visualize trends in disease or behavior across geographic areas (e.g., census tracts, zip codes or county). These pictures may inform both public health and primary care to drive targeted interventions. CHORDS expects to expand functionality by developing a cardiovascular disease registry with a focus on hypertension and hypercholesterolemia. The fellow would act as a convener meeting with CVD experts across sectors (providers, researchers, and community health workers) to define requirements for CVD registry functionality using evidence based CVD risk interventions,as a guide. The fellow will lead an effort to identify, define and operationalize cardiovascular disease clinical and population health key indicators. The fellow will translate knowledge into business requirements to inform the development of a cardiovascular disease registry. Fellow s Project Role: Leader Fellow s Deliverables: The fellow will be offered to participate in a variety of activities related to the HSIP competencies; working with the fellow, we will determine which activities meet her/his interests and needs. The fellow s activities will be customized based on interest and/or abilities. Possible activities and deliverables include:
Conduct a public health needs assessment on CVD surveillance including an environmental scan and literature review to inform the development of Denver CVD registry Summarize assessment findings and make recommendations for CVD registry structure and function Convene a group of CVD registry end users to review and prioritize CVD health indicators Conduct evaluation of CVD surveillance current state including aligning CVD priorities with current CVD data sources and defining gaps Define key CVD performance indicators and develop a comprehensive business requirements document Coordinate the development of CVD registry functionality within the CHORDS network Collect end user feedback to inform clinical tool user interface development Design and develop CVD surveillance and clinical indicator report cards Role of Community Engagement Partners: CCSTI, one of nearly 60 CTSA recipients nationwide, plays a leadership and technical role in the CHORDS development effort. CCTSI uses an innovated shared informatics resource model to support some of the most cutting edge informatics efforts in the region and nationwide. Dr. Michael Kahn, head of the CCTSI informatics core is a contributing member of the CHORDS Community of Practice as well as Jessica Bondy, director of the CCTSI shared resource project, who leads the technical development of CHORDS registries and plays a critical role building technical solutions to support governance efforts which ensure data stewardship best practices. DPH collaborates with CCTSI on a number of initiatives and the fellow will work with CCTSI experts in technical infrastructure and leadership to develop the structure and implementation plan for the Cardiovascular disease risk plug in. The fellow would join the CHORDS community of practice and collaborate on the development and implementation of the CVD risk, morbidity and mortality registry. Project 2 Title: QuitLine Linkage and Information Network for e-referral (Q-LINe) Project Description: Tobacco remains the leading cause of preventable premature death and disability in Colorado. Specifically, tobacco is a major contributor to 4 of the top 10 leading causes of death in Colorado: cardiovascular disease, cancer, chronic lung disease, and influenza/pneumonia. Because of the frequency of tobacco use and exposure to secondhand smoke and the breadth of the resulting serious health problems, decreasing tobacco use and exposure is the single most powerful tool we have to improve health in Colorado. Funded by tobacco settlement dollars, Colorado Department of Public Health and Environment and Denver Public Health collaborate with local healthcare providers to implement an electronic process to easily refer patients to tobacco cessation services. This Q-LINe project integrates electronic referrals (e-referral) from a patient s Electronic Health Record (EHR) to the Colorado Quitline. This e-referral will enable providers to directly communicate to the QuitLine without using a separate referral application, and increase the ease of referral, number of referrals, QuitLine
service utilization and likelihood of successful tobacco cessation intervention. The fellow will support implementation of e-referral at multiple Colorado healthcare providers participating in the documentation of the current state, worksite-specific e-referral workflow, system testing, and evaluation and quality improvement cycles. Fellow s Project Role: Participant Fellow s Deliverables: Our goal is to offer a variety of activities related to the HSIP competencies and to work with the fellow to determine which activities meet their interests and needs. The fellow s activities will be customized based on their interest and abilities. Possible activities and deliverables include: Convene bi weekly meetings of core e-referral web service technology partners to monitor and optimize e-referral systems, update the implementation guide, capture lessons learned and plan/inform future implementation efforts Conduct key informant interviews with provider s to describe and document provider workflow and referral data flow pre e-referral identifying opportunities to improve process. Conduct key informant interviews with providers gathering information to inform the ideal provider workflow to improve tobacco cessation referral. Define business requirements and standards for bidirectional message transfer using a webservice e-referral and Acknowledgment system Monitor emerging messaging and ereferral standards attending North American Quitline Consortium ereferral working group Develop and disseminate e-referral implementation manual Collect evaluation data including assessment of workflow impact, cost and required capacities for dissemination Incorporate evaluation findings into summary report and implementation guidance documentation Role of Community Engagement Partners: CORHIO is a nonprofit, public-private partnership that is improving health care quality for all Coloradans through cost effective and secure implementation of health information exchange (HIE). CORHIO is the Colorado state designated entity working to facilitate HIE, working with communities across Colorado to develop and implement secure systems and processes for sharing clinical information, including the QLINE efforts to implement an e-referral. The fellow will collaborate with CORHIO resources to ensure connectivity between healthcare providers and the Quitline for e-referral implementation as well as participate in high level conversations about implementation of all HIE functionality across the state.
Project 3 Title: ACA Implementation Monitoring and Evaluation Project Description: The Affordable Care Act s (ACA) expansion of health coverage options presents an incredible opportunity to improve health by increasing access to high quality healthcare and is perhaps the largest health systems integration effort occurring in Denver. Prior to the ACA, an estimated 17% of Denver residents were uninsured. Since the implementation of a Medicaid expansion and a local health insurance exchange, that percentage has been halved; over 60,000 previously uninsured Denver residents have gained coverage. Clinical and administrative data from safety net providers combined with data from enrollment sources (payers) and population-based uninsured survey data provides a web of information to evaluate the effectiveness of ACA implementation in Denver. These data inform health care decisions, health strategies, and delivery system design priorities for new ACA populations as well as those already insured. The fellow will support an analysis to study the early effects of the ACA Medicaid expansion in Denver on levels of health coverage, enrollment, and various primary care and utilization indicators and whether policy efforts and health services are adequately addressing health needs of the newly insured. The fellow will support development and assessment of population health indicators (mortality, health behaviors, and access-sensitive health outcomes) that could measure the effect of ACA on Denver residents. Health coverage and enrollment analysis will Identify and describe the remaining uninsured and newly covered population. The fellow will track enrollment progress by creating a ratio of estimated uninsured (the denominator) to successful enrollments (the numerator). This will assess the efficacy of outreach and remaining uninsured and eligible populations. Utilization and primary care use indicators will address questions of local and national interest. Have safety net healthcare facilities experienced a large influx of new patients? What are their demographic and health risk profiles? Does the safety net selectively retain or gain certain types of patients? What are utilization patterns for newly insured and their relative attachment to primary care sites? What are the anticipated health needs of previously and newly insured patients? What types of clinical services, QI programs, and population health efforts are needed? The fellow will act as a coordinator collaborating with community partners, healthcare providers, and administrators to develop and disseminate analytic findings in a meaningful way. Fellow s Project Role: Participant Fellow s Deliverables: Evaluation of the ACA implementation in Denver is a public health improvement plan priority for the City and County of Denver. Our goal is to offer a variety of activities related to the HSIP competencies and to work with the fellow to determine which activities meet their interests and needs. The fellow s activities will be customized based on their interest and abilities. Possible activities and deliverables include:
Actively participate in the Mile High Health Alliance Access to Care Coalition Develop reports and health communications materials that describe enrollment progress and disseminate to the community Convene community stakeholders to assess access to care related population health indicators and develop a population health analytic plan for ACA evaluation. Assess changes in enrollment and access to care using a eligibility, enrollment, and utilization data Analyze changes in enrollment, utilization, and population health and draft monitoring and evaluation summary reports, presentations, and white papers Collaborate to develop manuscripts describing methods and results for ACA evaluation in Denver Role of Community Engagement Partners: One in three children in Denver is cared for by Denver Health physicians as well.as Colorado's primary safety net institution, Denver Health has provided billions of dollars in uncompensated care. Denver Health is an integrated, efficient, high-quality health care system serving as a model for other safety net institutions across the nation. Denver Health's Ambulatory Care Services includes our primary care and specialty care services provided at a network of community health clinics and school-based health centers. Included in the ACS group is the Center for Health Services Research (CHSR) established to carry out patient-centered outcomes research in a safety-net health care system. Safety net healthcare systems, such as Denver Health s clinics and hospital, treat the underserved, underinsured, and uninsured, (25% of Denver) many of whom are members of racial and ethnic minority groups. CHSR was established with grant funds awarded by the Agency for Healthcare Research and Quality (AHRQ) HS022143. AHRQ s mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U. S. Department of Health and Human Services (HHS) and other partners to make sure that the evidence is understood and used. Researchers and providers at CHSR are leading the ACA evaluation and staff including Simon Hambidge M.D. Ph.D, the ACS Director, Tracy L. Johnson, Ph.D., M.A., Director of Health Care Reform Initiatives, and Rachel Everhart, Ph.D., Data Team Administrator will collaborate with the fellow to support ACA evaluation activities.