Can Health Information Exchanges Improve Public Health? Farzad Mostashari, MD SM New York City...
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Transcript of Can Health Information Exchanges Improve Public Health? Farzad Mostashari, MD SM New York City...
Can Health Information Exchanges
Improve Public Health?
Farzad Mostashari, MD SMNew York City Department of
Health and Mental Hygiene
Is There a Problem?
• State/local officials are not engaged• Inadequate representation of PH
perspectives (and state/local officials) in NHIN institutions
• A lost opportunity (at best)• Standards (and investments) that don’t
take PH into consideration could have negative impact
Active Government Role in NY
• NY City Mayoral EHR initiative– $27 million for interoperable EHRs
• NY State HEAL-NY Bond Grants– $53 million to 26 proposed HIEs (9 in NYC)– Requirement for “Public Health Reporting”
• DOHMH is partner in multiple HIEs• NYC Center of Excellence in Public
Health Informatics (CDC)
PCIP Roadmap1. Citywide EHR Network
• Procure “best of breed” Electronic Health Record • Add Public Health/Quality Improvement functionality• Prepare Network and Hardware Infrastructure• Extend to Correctional Health and community providers
2. Citywide Quality Improvement Network• Citywide automated quality measurement and reporting• Decision supports and other quality improvement• Extend to other ambulatory EHRs
3. Citywide Health Information Exchange Network• Interfaces to other systems (e.g., HHC)• Syndromic and Notifiable Disease Reporting• Citywide Immunization, Lead Registries, and School Health• Medicaid medication history• Linkages to RHIOs
DataRepository
CIS/EMR
Pharm
Lab
Radiology
Cardiology
ADT Inte
rfac
e E
ngin
e/A
PI
Participating Member (both care provider & data source)
Technical ComponentsStrawman
NYCLIX Layer
Member
•NYCLIX Layer can be provided by NYCLIX or internally built according to standards
•Member sends ADT for all patients registered/admitted
•Request for NYCLIX information can be initiated by member via Web or triggered via ADT in member’s ED
•Request for Member information is initiated by NYCLIX central to each member who has patient in record locator
NYCLIX Central
Participating Entity & Level
Patient matching & Record Locator
Aggregation & Standardization
Security Mgmt &Access Controls
NY
CL
IX A
ppl
icat
ion
Laye
r
1) All ADT from Member
2) NYCLIX Central Data Request
3) NYCLIX Data Source Result Inte
rfac
e E
ngin
e
Pre
sen
tatio
n
Care Provider Transactions
Data Source Transactions
NYCLIX Web
Center
•NYCLIX Central acts a clearing house for all requests and routes transactions based on participation level, patient matching, and record locator services
•ADT transaction from members comprise data supporting record locator and patient matching services. No clinical data is stored
•Security management and access controls govern who has access to what
Audit Trails
NYCLIX
PublicHealth
•NYCLIX Data Repository•NYCLIX Audit & Control
1) NYCLIX Care Provider Request
4) NYCLIX Central Result
PublicHealth
Pub Hlth
DataRepository
LabPharm PACS Cards ADT EMR
Interface Engine/ API
DataRepository
LabPharm PACS Cards ADT EMR
Interface Engine/ API
RHIO 1(MPI, Audit, Authentication, etc)
DataRepository
LabPharm PACS Cards ADT EMR
Interface Engine/ API
DataRepository
LabPharm PACS Cards ADT EMR
Interface Engine/ API
RHIO 2(MPI, Audit, Authentication, etc)
Prior Conceptual Framework• Leverage infrastructure developed for RHIOs- • Reduce burden of public health reporting requirements
• Standards-based messaging to population quality warehouse– Demographic (age group, zip, gender, “hashed ID”)– Encounter data (Chief complaint, disch. dx, dispo) – Problem list (Diabetes, CAD)– Physical exam (measured temperature, BP)– Procedures (mammo, colonoscopy, immuniz., eye exam)– Lab Results (A1C, lipids, viral testing results, lead)
• Functions– Clinical Preventive Services– Quality Benchmarking– Infection Disease and Outbreak Surveillance
GET
MessageTransferMessageTransfer
FIND
Patient IndexPatient Index
Provider asks if there are records for his/her patient Index sends
location ofany records
Sourcesends indexinformation
LOCATOR
Provider asksfor and receives
records
Recordsare sent to Provider
IndividualCare
Providers
IndividualCare
Providers
SEND
Source: © 2004 The Markle Foundation Graphic adapted from Tom Benthin original.
De-IdentifiedData
De-IdentifiedData
ReportingRouter
ReportingRouter
TING
Source may push data for
reporting
REPOR
DATA
PublicHealthPublicHealth
Health Information Exchange
DataSources
DataSources
10 Public Health Use Cases
Send• Mandated Laboratory Reporting• Mandated Clinical Reporting• Non-mandated Laboratory Reporting• Non-mandated Clinical Reporting• Population-level Quality ReportingFind6. Mass Casualty EventsGet7. Public Health Investigation8. Disaster Medical Response9. Patient-level Public Health Alerting10. Population-level Public Health Alerting
SEND
ReportingRouter
ReportingRouter
TING
Source may push data for
reporting
REPOR
DATA
PublicHealthPublicHealth
“Send”
DataSources
DataSources
• Interface engines and standardized clinical data repositories at each federated site
• Automated algorithms could identify and report events of public health significance directly from data sources
SEND
ReportingRouter
ReportingRouter
TING
Source may push data for
reporting
REPOR
DATA
PublicHealthPublicHealth
1. Mandated Laboratory Reporting
DataSources
DataSources
• Public health surveillance cornerstone• Electronic lab reporting improves timeliness, but
adoption has been slow due to local mapping• HIE’s standardized “edge” data repositories
could facilitate electronic lab reporting• Named data
SEND
ReportingRouter
ReportingRouter
TING
Source may push data for
reporting
REPOR
DATA
PublicHealthPublicHealth
2. Mandated Clinical Reporting
DataSources
DataSources
• Under-reporting by physicians very common• Automated algorithms could trigger review based
on diagnoses, medications, and procedures• Ambulatory EHR example (Klompas)• Named data
SEND
ReportingRouter
ReportingRouter
TING
Source may push data for
reporting
REPOR
DATAPublicHealthPublicHealth
3. Non-mandated Lab Reporting
DataSources
DataSources
• Not all diseases are “notifiable” by law
• Some common diagnoses (Abx resistance, viral dz) may not require individual action, but population trends can inform public health actions
• Anonymized or aggregated
SEND
ReportingRouter
ReportingRouter
TING
Source may push data for
reporting
REPOR
DATAPublicHealthPublicHealth
4. Non-mandated Clinical Reporting (“Syndromic Surveillance”)
DataSources
DataSources
• Pre-diagnostic data (e.g., ED chief complaints, measured temperature) tied to statistical algorithms can provide real-time outbreak alerting and disease trends
• Anonymized or aggregated
• Investigable
SEND
ReportingRouter
ReportingRouter
TING
Source may push data for
reporting
REPOR
DATAPublicHealthPublicHealth
5. Population-level Quality Reporting
DataSources
DataSources
• Core data elements (medications, procedures, diagnoses) needed for performance indicators
• Reporting to quality data warehouse
• pseudonymized or aggregated
Provider asks if there are records for his/her patient
Index sendslocation of
any records
Sourcesends indexinformation
LOCATOR
IndividualCare
Providers
IndividualCare
Providers
“Find”
DataSources
DataSources
Patient Index
• Master Patient Index
• Aka “Record Locator Service”
• Demographic data + ADT messages
Call center asks if there are records for missing person
Index sendslocation of
any records
Sourcesends indexinformation
LOCATOR
Emergency Call CentersEmergency Call Centers
DataSources
DataSources
Patient Index
6. Mass Casualty Events• Dislocation and confusion (9/11, Katrina)
• Common need to meet overwhelming volume of “missing person” requests
• RLS, limited to recent ADT messages
GET
Provider asksfor and receives
records
Recordsare sent to Provider
IndividualCare
Providers
IndividualCare
Providers
“Get”
DataSources
DataSources
Message transfer
• Individual queries for patient data
• Typically for treatment purposes
GET
Provider asksfor and receives
records
Recordsare sent to Provider
IndividualCare
Providers
IndividualCare
Providers
7. Disaster Medical Response
DataSources
DataSources
Message transfer
• Improved medical care (including public health issues) for dislocated individuals and refugees
• Authorization rules may be relaxed during emergency
GET
Public Health asksfor and receives
records
Recordsare sent to
Public Health
Public HealthPublic Health
8. Public Health Investigation
DataSources
DataSources
Message transfer
• Cases reported through other means (e.g., laboratory reporting)
• “shoe leather” epidemiology can be time consuming and labor intensive
• Rapid investigation feasible (“armchair”)
• Public health authorization to receive clinical data
GET
Provider asksfor and receives
records
Recordsare sent to Provider
IndividualCare
Providers
IndividualCare
Providers
9. Patient-level Public Health Alerting
PublicHealthPublicHealth
Message transfer
• Public Health acts as data source
• ED physician querying HIE could receive patient-specific public health alert (e.g. active TB, sought-for contact)
• Isolation, decreased nosocomial spread
• Early notification back to public health
GET
Provider asksfor and receives
records
Recordsare sent to Provider
IndividualCare
Providers
IndividualCare
Providers
10. Population-level Public Health Alerting
PublicHealthPublicHealth
Message transfer
• HIE serves as gateway for relevant epidemiologic data to providers (patients)
• Ideally in context of patient and practice (e.g. age/zip, ED vs. Ambulatory)– Trends in influenza or asthma– Antibiograms– Preventive services recommendations
GET
FIND
LOCATOR
Data Requestor
Data Requestor
SEND
TING
REPOR
DATA
DataSources
DataSources
10 Public Health Use Cases
Universal public health node? Universal Public Health Node
RHIO
Business ActorHospital / Healthcare Service Provider
Patient
HealthcareServiceProvided
Healthcare ServiceData Collection
Patient Query
Analytic Query
Line List Query
Anonymize & Reidentify
State / Local Health
Department, Federal
Government
Filter Data1.1.1.0, 1.2.1.0
Format Data1.1.3.0, 1.2.3.0
Identify Public Health Agency1.1.4.0, 1.2.4.0
Anonymize Data1.1.2.0, 1.2.2.0
Transmit1.1.5.0, 1.2.5.0
Receive Data1.3.2.0
Provide Listing of Required Data
1.3.1.0
Patient Queries:Mass Casualty- 311 Patient Locator Disaster Medical ResponseMandated ReportingPublic Health InvestigationTuberculosis All Points Bulletin (APB)
Anonymized Line Lists OR Analytic Queries:Non-Mandated Reporting
•Syndromic Surveillance•Viral (incl. Influenza) Surveillance•Abx resistance patterns•Quality Reporting
New RHIO Requirements?
• Ability to distribute analytic queries– Line lists– Aggregation queries (counts, num/denom)
• Anonymization & Reidentification• Aggregation with ability to drill down/ audit• Standard Health Query Language?• Messaging standards for aggregate
information?
Conclusion
• HIEs can have many potential benefits for public health agencies
• Demonstration of public health value may help sustain HIEs financially
• Involvement of public heath agencies in the design, governance, and funding of HIEs in their communities is necessary for these goals to be realized