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Harnessing Electronic Health Records
and Health Information Technology to
Achieve Population Health
Jonathan P. Weiner, DrPH
Professor of Health Policy & Management and of Health Informatics,
Director of the Center for Population Health IT (CPHIT)
The Johns Hopkins University, Baltimore Maryland, USA [email protected], www.jhsph.edu/cphit
Presented at the Institute for Health Technology Transformation
(IHT2) – NYC, NY. September 18, 2013
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The digitalization of medical care delivery is at a tipping point
Source: USDHHS, CDC-National Center for Health Statistics - 2013
THE OPPORTUNITIES FOR IMPROVING THE
HEALTH OF POPULATIONS WILL BE PROFOUND:
• Using EHRs linked to smart phones, a medical director could identify, monitor and improve the care of tens of thousands of persons with chronic diseases living in her community.
• A scientist could evaluate the community health impacts (and cost) of a new medical intervention in near real time.
• Social services, environmental health and medical care data could be fully integrated in real time to maximize health for targeted special populations in a geographic catchment area.
• Consumers, doctors, public health officers and nurse outreach workers could all share real time information and clinical guidance in the event of a disease outbreak.
• Based on public health analyses, an entire health delivery system could modify its standards of care within a few weeks of a major new scientific discovery.
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In this presentation I will discuss:
• Trends and frameworks related to electronic health records (EHRs), “e-health” and health IT (HIT) of special relevance to populations, communities and other target “denominators.”
• The potential for HIT to improve the:
health of populations and
the effectiveness and efficiency of integrated health care delivery systems.
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Medical Care / Clinical Sciences
Health Informatics /
HIT
Population / Public Health
Sciences 1
Population Health IT: Disciplines and Examples
Population HIT Examples: 1. Assessing community
health status & need
2. Public health surveillance 3. Improving performance
for populations served by integrated delivery system
4. Population decision
support for prevention / chronic care management
5. Consumer e-health in
support of wellness/ care management
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A few working definitions:
Healthcare Information Technology (HIT) - The application of
electronic health records (EHRs) and other digital technologies to the
delivery and management of health care. “Interoperable” EHRs
represent the backbone of a national healthcare information
infrastructure.
Health Informatics - The systematic application of information and
computer sciences and technology to health care practice, research,
and learning.
E-health - Health and health care practices supported by electronic
processes and communication. The term is inconsistently used: some
use it interchangeably with HIT. Others use it more narrowly as
consumer targeted health and health care support delivered or
enhanced through the internet or mobile (“m-health”) devices.
Healthcare Analytics - the leveraging of electronically
available healthcare data to enable actions that improve
health system effectiveness, efficiency or equity.
Population Health- A comprehensive framework for
assessing and improving the health and well being of a
defined population. Population health is practiced by private
and public organizations that focus on communities, persons
“enrolled” by a health care organization, or other groupings of
individuals that comprise a specific cohort of interest.
Public Health - Societal (i.e., government) actions to improve
health. The core public health functions relate to assessment,
assurance and policy setting.
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Working definitions – Cont.
CDC’s estimates of impact of each determinant on mortality and morbidity.
Social Determinants, Environment and Behaviors are Key to Achieving “Population Health”
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The e-health / HIT framework that will soon define
the “digital health care milieu”
Physician Patient
Practice Family Team
EHRs Web-Portals
M-health Apps
PHRs
e-mail / internet/ Social networks
Secure Messaging
ICT / wireless & wired
Biometric/ Telemed
CDS / POE
ACO= Accountable Care Organization EHR = electronic health record PHR = personal health record CDS = clinical decision support IT systems MIS/HIS = Management/Health IT systems POE = provider order entry IT systems
Claims/MIS/ HIS
PH/ HR IT
PH/HR = public health / human resource IT systems Telemed = telemedicine/ remote patient monitoring-M-health = mobile health applications ICT = information / communication technology
Source: Weiner, 2012 http://www.ijhpr.org/content/1/1/33
Applying HIT to achieve care
that is:
- Population focused
- High value, and
- Integrated
HIT and population health is core to the
Patient Centered Medical Home (PCMH)
Integrate
E-prescribing
And
COES
EHR/HIE
Connected
Public Health
Bio Surveillance
Connected
Two way Quality
Reporting
Electronic
Eligibility
System
Interface
Electronic
Patient Access
and
Communication
E-Clinical
Decision
Support
Patient
Registry
Databases
Advance
Chronic
Disease
Mgmt
Medical Home
2.0
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Source: US Medicare (CMS) Innovation Center
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Source: Premier Healthcare Alliance
HIT is core to the Accountable Care
Organization (ACO)
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Transforming Health Care Will Require
Paradigm Shifts and HIT Support
TRANSFORMED CURRENT
Coordinated /Integrated Care Fragmented Care
Patient / Population Focused Provider Centric
Payment for Value / Outcome Payment for Volume / Units
Care System Focused Individual Facility Focused
Care Team Accountability Physician Accountability
Transparency Opaque rules and systems
Wellness / Chronic co-morbidities Disease oriented / Acute Illness
Evidence-Based Care /Learning Organiz. Limited Basis for Clinical Action
See: Weiner –Executive Insight Magazine Nov 2011,:
http://healthcare-executive-insight.advanceweb.com/Archives/Article-Archives/Virtual-Glue-for-a-Transformed-Healthcare-System.aspx
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Key applications of HIT for “population health
decision support” within integrated delivery
systems
• Risk identification / stratification for targeting priority populations/patients
• Provider focused process improvement focusing on patient “denominators”
• Patient / consumer targeted care management and wellness using “e-health” / “m-health” tools
• High level monitoring of outcomes/value of the entire target population
Population Health Informatics at Johns
Hopkins (JHHC)
Inputs
Outputs
Case Manager Medical Directors Clinical
Management Team
Patient Care Reports
Provider Profile
ACG Risk Measures:
Scientific Knowledge:
clinical guidelines
Clinical / EHR/ Lab Results
Claims, Rx, Enrollment,
Self-reported Health Risk Data
Population Statistics Population Groups
Users
Informatics
Update Monthly
Review Annually
Update Monthly
Update Monthly
Claims/Operations Tables
Lab Results Tables
ACG Tables
Scientific Tables
Update monitored patient and clinical events tables
Monitored Patient Tables
Clinical Events Tables
Create Reports Routinely and on Demand
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Using Predictive Models to Identify Patients at Risk for
Future Hospitalization: Our Johns Hopkins ACG “PM” system is used in 18 nations
1.6%1.2%
3.0%
94% 6%
Distribution of JHU ACG "Probability of
Hospitalization" PM Risk Score
.3 to <= 1.0
.2 to < .3
.1 to < .2
.0 to < .1
0%
20%
40%
60%
80%
100%
.0 t
o <
.1
.1 t
o <
.2
.2 t
o <
.3
.3 t
o <
.4
.4 t
o <
.5
.5 t
o <
.6
.6 t
o <
.7
.7 t
o <
.8
.8 t
o <
.9
.9 t
o…
2%
28%
47% 59%
78%
100%
Percent Actually Hospitalized by ACG Predictive Model Risk Score
Scores Based on ACG Version 9.0 Hospitalization Prediction Risk Model - This is for a Medicaid Cohort enrolled in private health plans. (See: www.acg.jhsph.edu)
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Source: CMS Innovation Planning Grant Received by the Maryland DHMH
Hot-Spotting Baltimore Hospitalizations Using HIE Data
Johns Hopkins CMS Innovation Grant – Community Health Partnership
Grant Targeting Population in East Baltimore
Characteristics of high-risk group:
• 36% have 6+ chronic conditions.
• 47% have 1 or more hospital admissions
during Nov 2011- Oct 2012
• 1,117 total admissions (76% all
admissions)
• Total cost of care is $30 Million
• Average of $29,679 per person per year
Characteristics low/ moderate risk Group:
• 6% have one admission
• Total cost of care is $29 Million
• Average of $5,463 per person per year
High Complexity
1000 people at
six clinics
Moderate and Low
Complexity
5,258 people at six clinics
JHU ACG Risk Score Using JH EMR/HIT
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Pop HIT Challenges: We need
• To find ways to integrate disparate “numerators” & “denominators” to define true populations and communities.
• Models and tools to help medical care systems move towards population perspectives.
• Computer science / informatics technical tools that facilitate public health and population health operational needs. To date main focus has been on clinical and administrative issues.
• Advanced tools for extracting and analyzing unstructured data.
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Population Health IT Challenges - 2
• Standards and frameworks for integrating across EHR / IT vendors to achieve true community standards in this domain.
• New policy/legal frameworks and financial structures that support population focus.
• Closer collaboration between government, providers, payers/regulators, IT industry and academia.
• Viable models for supporting ongoing development and dissemination of evidence and tools in the population health IT area.
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The Johns Hopkins Center for Population Health IT (CPHIT) -- Mission and Focus
The mission of CPHIT (“see-fit”) is to improve the health and well-being of populations by advancing the state-of-
the-art of Health Information Technology (HIT) and e-health tools used by private health care organizations and
public health agencies.
CPHIT’s focus will be on the application of electronic health records (EHRs), e-health and other digitally-supported
health improvement interventions targeted at communities, special need populations and groups of consumers cared for by integrated delivery systems
(IDSs).
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1. Development and testing of health status and quality
measures created from EHRs and other HIT systems.
2. Use and advancement of computing methodologies –
including natural language processing (NLP) and pattern
recognition tools.
3. Initiation of effective approaches for linking provider-
centric EHR systems with consumer-centric internet and
mobile-based e-health applications.
4. Development of EHR-based tools and decision support
applications to help manage high risk populations.
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Some Key priorities of JHU CPHIT R&D Center
Scope of CPHIT’s Activities
• Establish a leadership role in the development of a national/global research agenda for population HIT.
• Undertake breakthrough and translational R&D and associated technology transfer.
• Establish a comprehensive R&D infrastructure with access to EHR data and a large cadre of multi-disciplinary Johns Hopkins University (JHU) faculty.
• “Industry Partners” program to initiate and maintain active collaboration with industry stakeholders.
• Further the education of the next generation of population health informatics specialists.
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Challenges, Opportunities Future
Directions
Further Information
Center Director
Prof. Jonathan Weiner, DrPH
[email protected], 410 955-5661
The Johns Hopkins Center for Population Health
Information Technology (CPHIT)
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www.jhsph.edu/cphit
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