Public Health IT Public health enabled Electronic Health Records, Decision Support, and Their Role in the Meaningful Use of Healthcare Technology Lecture b This material (Comp 13_Unit 4 b) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1 U 24 OC 000003.
EHRs, Decision Support, and Meaningful Use of HIT Learning Objectives • Demonstrate knowledge of public health-oriented clinical decision support including an integrated strategy using multiple tools such as alerts, order sets, smart forms, and quality reporting (Lecture b) • Describe the strategies, features, and systems needed for public health agencies to define and build the necessary connections to EHRs as identified by the "meaningful use" legislation (Lecture b) • Identify the essential features of four primary public health IT functions including syndromic surveillance, bidirectional immunization registries, public health alerts, ad-hoc reporting, etc. (Lecture b) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 2
8 Key Features of ECW 1. Measure Reports Side-by-side provider comparisons of performance on quality measures 2. Enhanced Registry Identifies patients by structured data (e. g. , diagnoses, drugs, labs, demographics) 3. Automatic Visual Alerts Highlights abnormal vitals 4. CDSS Automatically displays preventive service alerts that are suppressed when addressed Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 3
8 Key Features of ECW (cont. ) 5. Quick Orders One-click ordering of recommended preventive services 6. Comprehensive Order Sets Displays best practice recommendations (e. g. , for meds, labs, patient education) 7. CIR and School Health Sends information to City Immunization Registry & generates school health forms 8. Medication History With patient consent, displays a medication history of all Rxs filled by the patients Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 4
The following storyline… • Illustrates these Public Health-enabled EHR functions in action • Jane Doe, a 48 year-old woman is cared for by her family practitioner, Dr. Sam Willis Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 5
1. Measure Reports 5. Quick Orders Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History Dr. Willis wants to find out how he is performing compared to other physicians in his practice in controlling high blood pressure for his patients. Using the QUALITY MEASURE REPORTS FUNCTION, Dr. Willis finds that only one-third of. Health IT hypertensive patients his Public Health IT Workforce Curriculum EHRs, control. 6 have achieved good BP Decision Support, and b. Meaningful Use of HIT Version 3. 0/Spring 2012 Lecture
Enhanced Registry 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History Dr. Willis wants to improve his score on BP control and queries the EHR to identify patients with poorly controlled hypertension. Using the ENHANCED REGISTRY FUNCTION, Dr. Willis identifies five patients with high Health IT pressure who do not blood Public Health IT Workforce Curriculum have an appointment. EHRs, Decision Support, andand reaches out to each scheduled, b. Meaningful Use of HIT Version 3. 0/Spring 2012 Lecture 7
Automatic Visual Alert 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History • Jane Doe receives the letter and makes a f/u appointment • During the visit, Dr. Willis’s assistant takes her history and vitals • Jane mentions that she has had a few weeks of excessive thirst and fatigue Jane’s blood pressure is elevated (150/90) and highlighted in red by the AUTOMATIC VISUAL ALERT FUNCTION. Dr. Willis can trend her BP over time. (Buck, IT Workforce Curriculum Health 2010. ) Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT 8
CDSS 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History • Based on Jane’s chief complaint of excessive thirst, Dr. Willis performs a fingerstick test and confirms his suspicion that Jane has diabetes • Dr. Willis enters a diagnosis of diabetes into the EHR Based on Jane’s new diagnosis of diabetes, the CLINICAL DECISION SUPPORT FUNCTION identifies four preventive care services that should be performed. This list of services is automatically populated in the CDSS panel. (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 9
Quick Orders 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History Dr. Willis agrees that these tests are appropriate and should be performed Dr. Willis uses the QUICK ORDER FUNCTION to order an Hb. A 1 C test for Jane, as well as a flu vaccine; the alerts disappear from the panel once they are ordered. Dr. Willis may also choose to suppress alerts, if he deems them unnecessary. (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 10
Comprehensive Order Set (Pt I) 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History Dr. Willis also selects the “LDL control (high risk)” alert, which displays the order set for high LDL levels The 1 st part of the COMPREHENSIVE ORDER SET displays a selected list of recommended medications (brand & generic) for lipid control. (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 11
Comprehensive Order Set (Pt II) 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History Dr. Willis views other order sets for high LDL levels The 2 nd part of the COMPREHENSIVE ORDER SET displays a selection of recommended labs, immunizations, follow-up appointments, referrals as well as printable physician and patient education materials. (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 12
CIR and School Health 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History • While she’s there, Jane asks Dr. Willis for a school health form for her 5 yearold (Tim) who is entering day care. • Dr. Willis generates a preloaded NYC School Health form populated with Tim’s information for Jane to take with her. Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 13
Citywide Immunization Registry Tim’s information has already been automatically uploaded to the CITYWIDE IMMUNIZATION REGISTRY. The CIR will maintain a complete record of Tim’s immunizations which can be accessed by other providers as needed. Health 2010. ) (Buck, IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 14
Medication History Function 1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS 5. Quick Orders 6. Comprehensive Order Sets 7. CIR and School Health 8. Medication History • Dr. Willis wonders if he should change Jane’s medication regimen to better control her lipids and wants know what medications have been filled by her • Jane has signed a consent form to give the provider access to her medication history Dr. Willis can use the Medication History function to view her 90 -day medication history. He notices that Jane has not filled her lipid medication (simvastatin) for the past three months; she admits that she has stopped taking them because she wondered if her tiredness might have been due to these pills. (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 15
Public Health Meaningful Use Functions Syndromic Surveillance Immunization Registries Public Health Alerts & Adhoc Reporting Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 16
Syndromic Surveillance • Syndromic surveillance is a Meaningful Use function Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 17
Syndromic Surveillance System • The syndromic surveillance system was designed and built in Sept/Oct 2008 by PCIP and deployed in November 2008 • Syndromic definitions for Influenza-like Illness (ILI), Fever, and Gastrointestinal Illness are encoded using My. SQL database queries • Executed in a nightly batch job, with results reported securely through SFTP to PCIP Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 18
System Screenshot (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 19
Syndromic Data • Only “Count Data” is collected Measure ID Measure Name 9000 ILISyndromic 9001 Fever. Syndromic 9002 Influenzal. CD 9 ONly 9100 GISyndromic 9100 GISyndromic Table 1. 1 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Report Date Time Age Group 1/23/2010 22: 50 b_2 to 4 years 1/24/2010 22: 50 d_12 to 16 years 1/25/2010 22: 50 e_17 to 44 years 1/26/2010 22: 50 h_All. Ages 1/27/2010 22: 50 a_0 to 1 years 1/28/2010 22: 50 b_2 to 4 years 1/29/2010 22: 50 d_12 to 16 years 1/30/2010 22: 50 e_17 to 44 years 1/31/2010 22: 50 h_All. Ages 2/1/2010 22: 50 a_0 to 1 years 2/2/2010 22: 50 b_2 to 4 years 2/3/2010 22: 50 d_12 to 16 years 2/4/2010 22: 50 e_17 to 44 years 2/5/2010 22: 50 h_All. Ages 2/6/2010 22: 50 a_0 to 1 years 2/7/2010 22: 50 b_2 to 4 years 2/8/2010 22: 50 d_12 to 16 years 2/9/2010 22: 50 e_17 to 44 years 2/10/2010 22: 50 h_All. Ages Patient Numerator Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b Patient Denominator 0 2 0 3 0 2 1 9 1 2 0 3 0 2 1 9 0 2 0 3 0 2 0 9 0 2 1 2 0 3 0 2 1 9 20
7 Day Average % of ILI Visits by Age Group (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 21
All Ages % of Visits Related to ILI (Buck, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 22
EHRs, Decision Support, and Meaningful Use of HIT Summary – Lecture b • This lecture has shown that a combination of measure reports, registry tool, visual alerts, clinical decision support, order sets, CIR, and medication history all enable a clinical provider to practice good preventative followup care in-line with public health priorities. It has also shown how EHR data could be used to detect the H 1 N 1 flu outbreak in New York City. Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 23
EHRs, Decision Support, and Meaningful Use of HIT References – Lecture b References 1. Plagianos M, Buck MD, et al. Syndromic Surveillance during Pandemic (H 1 N 1) 2009 Outbreak. Emerging Infectious Diseases. 2011 Sept; 17(9). 1724 -6. 2. Amirfar S, Taverna J, Anane S, Singer J. Developing Public Health Clinical Decision Support Systems (CDSS) for the Outpatient Community in New York City: Our Experience. BMC Public Health. (Accepted for publication) Images Slide 6 -14 & 18: Buck, M. (2010). Example images of eclinicalworks: personal desktop. New York Department of Health and Mental Hygiene, Primary Care Information Center. Slide 20: Buck, M. (2010). 7 Day average percent of ILI visits by age group. New York Department of Health and Mental Hygiene, Primary Care Information Center. Slide 21: Buck, M. (2010). All ages percent of visits related to ILI. New York Department of Health and Mental Hygiene, Primary Care Information Center. Charts, Tables, Figures 1. 1 Table: Buck, M. (2010). Syndromic data. New York Department of Health and Mental Hygiene, Primary Care Information Center. Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT EHRs, Decision Support, and Meaningful Use of HIT Lecture b 24
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