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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 Jweiner@jhsph.edu, 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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3 4

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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

jweiner@jhsph.edu, 410 955-5661

The Johns Hopkins Center for Population Health

Information Technology (CPHIT)

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www.jhsph.edu/cphit