HealthInforma.cs

Lecture2

SamanthaKleinbergsamantha.kleinberg@stevens.edu

Overviewoftoday’sclass

•  Whereishealthdatacollected?•  Whyisitcollected?

– AndwhythismaEersforinterpre.ngit!

Whathealthdataarewetalkingabout?

•  Hospitals/providers–  Electronicmedicalrecords(moredetailnextweek)–  ICUdata(canbeoutsideEMR)

•  Claimsdata –  Insurancecompanies,Medicare

•  Pa.entgenerateddata–  Personalhealthrecords(nextweek)–  Selftracking– Onlineforums

Differentpurposes•  Hospitals/providers

–  Documen.ngwhatwasdoneandwhy–  Documenta.onforreimbursement–  Communica.onamongcareteam–  Legal–  Preven.on–  Research

•  Claimsdata –  Mainly$

•  Pa.entgenerateddata–  Personalinterest–  Socialsupport–  Sharewithprovider

Differentavailability

•  Hospitals/providers– Researchcollabora.on– MIMICIII

•  Claimsdata– CenterforMedicare&Medicaid(CMS)datasets

•  Pa.entgenerated– Seetermsofserviceforapps/forums– Datacanbedonatedbyusers

Whygodigital?

•  Youcan’tgrepadeadtree(search)•  Abilitytosharedata•  Preventdataloss•  Storemoreinforma.onthanphysicallypossible

•  Standardize(morelater)

Abriefhistoryofmedicalrecords

•  1960’sLarryWeedintroducesProblemOrientedMedicalRecord(POMR)–  InsteadofjustDx/Tx,medicalhistory

Newauthor

Problemorientedrecord

Keyadvances

•  Problemlist•  SOAP

– Subjec.ve– Objec.ve– Assessment– Plan

•  1960s/70s–FirstEHRs,butthey’re$$$andnotwidelyadopted.VAadoptsEHR

•  1990s–Riseofpersonalcomputers+Internet–  Ins.tuteofMedicinesetstargetforallphysicianstousecomputersby2000(realitywas<20%)

– Manyhospitalscreatetheirownrecordsystems*

•  2000s–HITECH/ARRAandmeaningfuluse–  Incen.vestoencourageadop.on

Meaningfuluse

•  Incen.vesfornotjustadop.ngEHR,butusingthemtoimprovecare

•  3componentsfromARRA(2009)– UsingEHRinmeaningfulway– Exchanginghealthinforma.ontoimprovequalityofcare

– UsingEHRtosubmitclinicalqualityandothermeasures

ExamplesofprimaryusesofEHR

•  Ordertests,medica.ons•  Billing•  Documenta.on(admission,discharge,careplan,medicalhistory,etc)

Stages

Healthit.gov

2019

Stage2objec.ves

1.  Protectelectronicprotectedhealthinforma.on

2.  Electronicprescrip.ons3.  Healthinforma.onexchange4.  Pa.ent-specificeduca.on5.  Medica.onreconcilia.on6.  Pa.entelectronicaccess7.  Publichealthrepor.ng

•  Keyupdatestopa.entengagement–  Insteadof5%ofpa.entsforelectronicaccess,now>=1pa.entduringrepor.ngperiod

–  Insteadof%usingsecuremessaging,nowjustcapabilityofsecuremessaging

•  Removedsomedatacollec.onrequirements– Demographics,smokingstatus,familyhistory

hEps://dashboard.healthit.gov/quickstats/pages/FIG-Hospital-Adop.on-of-Pa.ent-Engagement-Func.onali.es.php

hEps://dashboard.healthit.gov/quickstats/pages/physicians-view-download-transmit-secure-messaging-pa.ent-engagement.php

Stage3-interoperability

•  Sharedata– %ofpa.entsmessageprovider– Electronicsummariesforotherproviders

•  Other– %ofelectronicprescrip.ons/orders

•  Handlepa.ent-generateddata– %generated

Availabledata

•  Allprovidersdemonstra.ngmeaningfuluseandreceivingpaymentlistedpublicly,updatedquarterly

•  hEp://www.cms.gov/Regula.ons-and-Guidance/Legisla.on/EHRIncen.vePrograms/DataAndReports.html

MedicareMerit-basedIncen.vePaymentSystem

•  Firstyearofrepor.ngwas2017,measuressubmiEedMarch18,paymentchangesJan12019

•  Reimbursements-9%to+27%•  Factors

– Quality(60%)–  Improvement(15%)– Advancingcareinforma.on(meaningfulusereplacement)(25%)

Who’scollec.ngdata(hospital)?

•  Doctors(aEendings,residents,interns)•  Nurses•  Lab•  Radiology•  Pharmacy•  Admin/staff

Primaryvssecondaryuse

•  ExampleprimaryusesofEHR– Deliveringcare:ensuringcon.nuity,documentmedicalhistory

– Billing:documen.ngservicesprovided

•  ExamplesecondaryusesofEHR– Research:findcausesofdisease,iden.fydrug-druginterac.ons

– Publichealth/policy:iden.fydiseaseoutbreaks

Informa.onexchange

Healthit.gov

Informa.onexchange

•  Withinhospital – Betweenunits,peoplewithdifferentroles,etc

•  Betweenmul.pleorganiza.ons – Primarycare+specialist,etc

Fig.2Schema.clayoutoftheCTICUandkeyac.vi.esduringwhichobserva.onswereconducted.Pa.entcubiclessurroundtheNursingsta.onwheremostoftheclinicalinforma.onsystemslie.TheleEersonthehumanrepresenta.onssignifythefollowi...

Malhotra,S.,Jordan,D.,Shortliffe,E.&Patel,V.L.,2007,Workflowmodelingincri.calcare:piecingtogetheryourownpuzzle,Journalofbiomedicalinforma0cs,40(2),pp.81-92

Exchange–withinICU

Malhotra,S.,Jordan,D.,Shortliffe,E.&Patel,V.L.,2007,Workflowmodelingincri.calcare:piecingtogetheryourownpuzzle,Journalofbiomedicalinforma0cs,40(2),pp.81-92

Fig.6Thecogni.veworkflowmodelforinpa.entcare.Theworkflowflowsinanan.-clockwisefashion.Althoughthisbeingacon.nuouscyclewithnostartorfinish,thesymbolofthesun(morning)canbeusedasthestar.ngpoint.Pleasenotethethreelevelsofabstrac.on(seetextfordetails):(a)thecompleteworkflowmodelastoplevel,(b)thegroupedCZsshownwithdifferentbackgroundcolors—1through3,(c)theindividualcri.calzones—1through7.The4thlevelistheindividuallevelwhichwasshowninFig.5withtheaEendingasanexample.

Malhotra,S.,Jordan,D.,Shortliffe,E.&Patel,V.L.,2007,Workflowmodelingincri.calcare:piecingtogetheryourownpuzzle,Journalofbiomedicalinforma0cs,40(2),pp.81-92

Informa.onexchange–over.me

Amir,O.,Grosz,B.J.,Gajos,K.Z.,Swenson,S.M.andSanders,L.M.Fromcareplanstocarecoordina.on:Opportuni.esforcomputersupportofteamworkincomplexhealthcare.InCHI,2015.

Whyisinforma.onexchangeimportant?

•  Reduceduplicatetests•  Improvediagnosisandtreatment

– E.g.Medica.oninterac.ons,allergies– Resultsofpriortes.ng/diagnosesruledout

•  Reduceerrors/improveefficiency– Eg.Askingforfamilyhistoryrepeatedly

•  Research!Feedbackloop,missingdata

Whyisinforma.onexchangehard?

•  Pa.entmatching•  Preservingprivacy•  Differingdataformats

HowcanCShelp?

What’stheprac.calimpact?

•  StudytookallmajoremergencydepartmentsinMemphis,comparedoutcomeswithHIEandwithout

•  Access:6.8%ofEDvisits(12EDs),associatedwithdecreasedhospitaladmissions

•  Cost:es.mateHIEreducedoverallcostby$1.07million(primarilyduetoreducedadmissions) Thefinancialimpactofhealthinforma1onexchangeonemergency

departmentcareMarkEFrisse,KevinBJohnson,HuiNian,CodaLDavison,CynthiaSGadd,KimMUnertl,PatATurri,QingxiaChenJAmMedInformAssocamiajnl-2011-000394PublishedOnlineFirst:4November2011doi:10.1136/amiajnl-2011-000394

Study design.

Frisse M E et al. J Am Med Inform Assoc doi:10.1136/amiajnl-2011-000394

Copyright © by the American Medical Informatics Association. All rights reserved.

HIEModels

•  Directexchangebetweencareproviders– Ex:Doctorreferspa.enttospecialistforfollow-up,andsendsbriefhistory

•  Centralorganiza.on– many-to-many

•  Pa.entmediated– EX:PHR,bringingpaperrecordstoappointment

Directexchange

•  Pushinginfotopublichealthregistries,sendingordersandresultstoclinicians

•  Challenges?

•  Differentdataformats•  Dependsonindividualsreques.ng/matchingpa.ents

Pa.entexchange

(consumermediatedexchange)•  Pa.entsshareaccesswiththeirproviders•  Insomecases,cancorrecterrors,addinforma.on

Noteonpa.entaccess…

•  Pa.entshavetherighttoseetheirmedicalrecord– Andtohaverecordsenttoathirdparty

•  Demonstra.ngaccessisimportantformeaningfuluse!

VABlueBuEon

•  EnableVApa.entstodownloadmedicaldatawithoneclick

•  Launchedin2010•  SharewithMD,otherservices(e.g.Microso|HealthVault)

VAbluebuEon–pa.entexchangeexample

hEp://www.youtube.com/watch?v=lGGnda44Yik

However…

Peoplehideinforma.on– Labtestsunderassumedname– Seekinganoutofstateproviderratherthanprimarycare

– Givingfalseinforma.on– Simplynotgivinginforma.onwhenrequested

13-17%ofconsumersinrecentsurveyssaythey’veengagedininforma.onhidingintheirrecord

Datafromoutsidehospital?

hEp://vimeo.com/81272562

Today’spaper

•  What’stheproblem?Whyistheapproachnovel?•  Whatchallengescomewithnon-randomizednon-blindedtrials?

•  Whatresultsshouldwebeskep.calabout?•  Whatdidtheyfindandhow?•  Cannon-randomizedtrialresultseverbestrongerthanRCTresults?

•  Ques.ons/cri.cisms?

BacktoHIEModels

•  Directexchangebetweencareproviders– Ex:Doctorreferspa.enttospecialistforfollow-up,andsendsbriefhistory

•  Centralorganiza.on– many-to-many

•  Pa.entmediated– EX:PHR,bringingpaperrecordstoappointment

Querymodel

•  Alicecomestoemergencyroom,physicianwantstogetallofAlice’srecordsfromallofherproviders

HIOs

•  HealthInforma.onorganiza.ons•  RegionalHIO

– Servesaspecificgeographicarea•  HII(healthinforma.oninfrastructure)•  NHII=na.onalHII,e.g.connectedRHIOs

WhyNHII?

•  Biosurveillance•  Fullsharingofrecords•  Integra.onwithpublichealth•  Clinicaltrials

Shortliffe,E.H.&Cimino,J.J.,2013,BiomedicalInforma0cs:ComputerApplica0onsinHealthCareandBiomedicine,SpringerVerlag.

Shortliffe,E.H.&Cimino,J.J.,2013,BiomedicalInforma0cs:ComputerApplica0onsinHealthCareandBiomedicine,SpringerVerlag.

Pa.entmatching

•  Basicproblem:HowdoweknowJoeSmithatHospitalAisthesameJoeSmithatHospitalB?

•  Effectsofincorrectmatch– Medicalerrors:e.g.missingallergy/incorrectallergy

– Lossofprivacy:disclosinganotherpa.ent’sinfo•  Challenges

– Missingdata,highlyscaEeredrecords,commoncharacteris.cs

UPI

•  Everyonegetsa“uniquepa.entiden.fier”(UPI)

•  SSNo|enused,thiswouldreplacethat

•  What’sarepros/cons?Isitabiggersecurityrisk?

•  Note:congresshasbannedfundingHHStoinves.gateUPIs

Otherapproaches

•  Algorithmic•  Biometric

hEp://www.healthit.gov/sites/default/files/pa.ent-matching-white-paper-final-2.pdf

hEp://www.healthit.gov/sites/default/files/pa.ent-matching-white-paper-final-2.pdf

Challenges

•  Datamaybe…– Missing–  Incorrect– Outdated

Fornextweek

Read:S.Abhyankar,D.Demner-Fushman,F.M.Callaghan,andC.J.McDonald.Combiningstructuredandunstructureddatatoiden.fyacohortofICUpa.entswhoreceiveddialysis.JournaloftheAmericanMedicalInforma.csAssocia.on