Can Health Information Exchanges Improve Public Health? Farzad Mostashari, MD SM New York City Department of Health and Mental Hygiene [email protected]

Can Health Information Exchanges

Improve Public Health?

Farzad Mostashari, MD SMNew York City Department of

Health and Mental Hygiene

[email protected]

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



RHIO 1(MPI, Audit, Authentication, etc)

DataRepository



DataRepository



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


reporting

REPOR

DATA


“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


reporting

REPOR

DATA


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


reporting

REPOR

DATA


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


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


reporting

REPOR


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


reporting

REPOR


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


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


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


records


IndividualCare

Providers

IndividualCare

Providers

“Get”

DataSources

DataSources

Message transfer

• Individual queries for patient data

• Typically for treatment purposes

GET


records


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


records


IndividualCare

Providers

IndividualCare

Providers

9. Patient-level Public Health Alerting


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


records


IndividualCare

Providers

IndividualCare

Providers

10. Population-level Public Health Alerting


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

Documents

Can Health Information Exchanges Improve Public Health? Farzad Mostashari, MD SM New York City Department of Health and Mental Hygiene [email protected]