how to create information systems with data that flow both ways

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Arthur Davidson, MD, MSPH Denver Public Health [email protected] Committee on Recommended Social and Behavioral Domains and Measures for Electronic Health Records National Academies of Sciences Building 2101 Constitution Avenue NW Washington, DC 20418 April 8, 2014 1 How to Create Information Systems With Data that Flow Both Ways Linking EHRs Between PH, Social Service Agencies, and Other Relevant Organizations

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Linking EHRs Between PH, Social Service Agencies, and Other Relevant Organizations. How to Create Information Systems With Data that Flow Both Ways. Arthur Davidson, MD, MSPH Denver Public Health [email protected] - PowerPoint PPT Presentation


  • Arthur Davidson, MD, MSPHDenver Public [email protected] Committee on Recommended Social and Behavioral Domains and Measures for Electronic Health RecordsNational Academies of Sciences Building2101 Constitution Avenue NWWashington, DC 20418April 8, 2014*How to Create Information Systems With Data that Flow Both WaysLinking EHRs Between PH, Social Service Agencies, and Other Relevant Organizations

  • AgendaConceptual ModelLinkage for Public Health SurveillanceLinkage for Public Health InterventionNext Steps

  • Linkage Conceptual Model ClinicalCare (EHR)Public Health SocialServiceSchools/ChildcareQuitline

  • Linkage for Public Health Surveillance(Colorado)Transparent, distributed data networkModeled on the Mini-Sentinel (FDA) project and local experience with HMO Research Network (AHRQ) projectGovernance Voluntary participation; unlike mandated reporting, data use agreements established/requiredPrivacyMinimal data necessary to achieve stated goal (de-identified to start)Technical Infrastructure: 1) common data model, 2) emphasize data quality assessment, and 3) federated query tool

  • Linkage for Public Health Surveillance(Colorado)Colorado Health Observation Regional Data Service (CHORDS)Provide a "laboratory" to develop and evaluate scientific methods to support public health surveillance Afford Denver Metro and Colorado communities an opportunity to use existing EHR data systems for public health surveillanceLearn about barriers and challenges, both internal and external, to building a viable and accurate system of surveillance for public health events (e.g., conditions, behaviors and outcomes)Build an event agnostic infrastructure for public health surveillance, quality assessment, and research

  • e.g., Kaiser Permanente

    CHORDS RegistriesColorado Health Observation Regional Data Service Standard (Virtual) DataWarehouse

    CHORDSQuery Service(PopMedNet )PMNSecure federatedquery

    Current registry efforts:BMICVD riskTobacco use and SHS exposureMental healthColorectal cancerAdult obesityPMNCliente.g., Denver HealthStandard (Virtual) DataWarehouse

    PMNClientSecure federatedqueryAuthorize


  • Capacity to Support Multiple Conditions

    CHORDS Project SourceYearsColorado Clinical Translational Science Institute focused on regional informatics infrastructure for research; existing Cancer Center informatics expertiseNIH2008-2018Grant allowed initiation of virtual data warehouse (VDW) at Denver Health complementing Kaiser Permanente local expertiseAHRQ2010-2012Evaluation resulted in selection of Mini-sentinel PopMedNet model used FDA post-marketing surveillance2012-2013BMI monitoring including social and environmental and dataTCHFKP-CB2011-2013Cardiovascular risk reduction - Community Transformation GrantCDC2011-2016Tobacco use, second hand smoke exposure and cessationCDPHE2012-2015Mental health and substance useAHRQ2013-2017

  • Link Clinical, Social and Environmental Data Across Multiple Delivery SystemsPre-CHORDS (e.g., weight status surveillance):BRFSS self-reported demographic, weight data Survey ~12,000 Colorado/year = 700 Denver/yearAllows county-level estimates onlyCHORDS state:Combine measured BMI data from multiple institutionsInclude demographic data, residence location (geo-code)Link geographically aggregated BMI data (e.g. census tract) with social and environmental dataIdentify place-based interventions (e.g., social marketing, community resource development, and policy initiatives)Pilot features of local data sharing network

  • Types and Sources of Geo-coded Social and Environmental Data for Mapping

    DataSourceData typeGrocery storesReference USAPoints, aggregated into census tractsRestaurantsReference USAPoints, aggregated into census tractsFood Deserts (USDA definition)USDA Economic Research CouncilAt census tract levelWalkability (based on number of street intersections per unit area)Streetmap USA/ ESRI web distributionPoints, aggregated into census tracts Green space/parksFrom wide variety of sourcesPolygons (areas) , with points of park entrancePovertyAmerican Community SurveyPolygons (areas), aggregated into census tracts

  • Combined Measured BMI DataDenver County (valid BMI) :all ages: 184,644 (31%)adults: 119,075 (26%)children: 64,606 (51%)Coverage varies widely:> 50% for some communitiesfew with aberrant results

    CHORDS BMI Registry DescriptionChildren

  • Proportion of Children with a Valid BMI, Denver

  • Proportion of Adults with a Valid BMI, Denver

  • Proportion of Children with Obesity, Denver

  • Percent Overweight + Percent of Families in Poverty

  • Personal Prescription - example

  • Linkage Conceptual Model ClinicalCare (EHR)Public Health SocialServiceSchools/ChildcareQuitline

  • e-Referral between EHR and QuitlineGoal: Efficient EHR-mediated e-Referral (including patient preferences) to Quitline and timely acknowledgement/status messages returned to and posted within the EHR.

    North American Quitline ConsortiumConsensus process with ~15 Quitline vendors/service providersMessage requirements: Content: define common data elementsStructure: HL7 2.x and c-CDA formatsTransport: sFTP, Direct, web-service (WSDL-SOAP)

  • What next?CHORDSBuild out standard data model (i.e., add tables, required content/variables [IZ], extend time range)Conduct comprehensive data quality assessmentCompare member-vs. visit-based denominator estimatesExpand stakeholders (PH and clinical)Address duplicatesQuitlineSet e-Referral standards, assure meets PH needsVet with EHRA and standards development organizationConsider as model for PH related HIE and e-referral for other community-based services

  • Sustainability strategyEnhance event agnostic distributed surveillance/research network (e.g., breadth of use cases and stakeholders, depth of content)Study utility of system to multiple stakeholders (i.e., communities, elected officials, and individuals)Facilitate incorporation of new social/environmental data (e.g., barriers and assets)Standardize approach to geocoding and de-duplicationTarget outreach and community-based interventions (i.e., policy, systems and environmental changes) to those who need themAssess impact on health disparities reductionDevelop cadre of applied researchers and methods

  • Discussion/Questions?

    **Conceptual model:Start with 3 entities as described in the title where bidirectional information exchange is represented by arrows. Add 2 examples of other: Quitline (million hearts campaign) available to the estimated 42 million (18% of adult population) and Schools/Childcare where nearly 80 million (26% of population above 3yo) are enrolled. Definitely a need for linkage just based on shear volume.At least one use case per arrow.The key operational word in the session title is how; suggest one approach being tried in COnot always a direct path requires frequent course corrections based on local conditionscollective experience with many individuals and organizations within COLimited time today to explicate every arrow or linkage exampleSchools/Childcare exchange with Public Health: need immunization records which reside in PH space; PH wants to inform S/C of targeted IZ effortsPH has knowledge (e.g., IZ history and IZ-CDS rules) which schools need to evaluate vaccination efforts for their own childrenpotential open-source web service - rather than each S/C (or clinical care site) building their own rules.Social Service (SS) exchange with Schools/childcare or clinical care: how would a variety of SS data (e.g., WIC, child/elder abuse, home health) help inform schools/childcare. how would knowledge of recent release from or ongoing treatment for behavioral, psychiatric or correctional care be an important factor in clinical care (e.g., Hep C, HIV) Clinical care - Public health: from a MU perspective IZ has a well developed and operating bidirectional data flow use case across much of the country; ELR is typically unidirectional but PH has the capacity to aggregate data and return useful antibiograms to inform clinical practice and reduce unnecessary antibiotic use; Syndromic data have been provided back to communities to support informing interventions heat related injuries, GI outbreaks, ILI.Lastly, other areas of interest include registries and case reporting.The main focus of this presentation will be around registries. Case reporting requires knowing what are the reportable diseases for the jurisdiction of interest. Hope is that CSTE and CDC will be the source of truth for EHRs to know exactly which diseases and what forms are required to meet reporting requirements. Those are defined in the Reportable Condition Knowledge Management System (RCKMS).

    *Holmes J et al. Clinical Data Warehouse Governance for Distributed Research Networks in the United States: a Systematic Review of the Literature. JAMIA ( in press)Rosati, K. et al. HIPAA and Common Rule Compliance in the Mini-Sentinel Pilot, White Paper, July 2010. Brown JS, et al. Data Quality Assessment for Comparative Effectiveness Research in Distributed Data Networks. Med Care 2013;51:S22-S29*How we achieve bidirectional exchange is highly predicated on:long-standing partnerships between all of these entities and othersProcess driven by a number of cross-institutional studies and surveillance projectsCommunity engagement build tools consistent with county health department needs (Community Health Assessment and Community Health Improvement Plans)Real hunger for data to monitor; focus on obesity and getting the community and advocacy group working on childhood obesity. There is a the impact of programs both in the clinical and community areas.Aligned leadership NIH and NCI funding sites at UCD that are participants and driving technology evaluation and implementationNeed to carefully review the purpose of HIE is it research or public health surveillance; does IRB need to review or does 164-512(b) provision in HIPAA make these IRB reviews unnecessary.

    *What are the reports that we could use:Community based organizations, advocacy groups, civic leadersPublic health officialsPoint of care