The Role of Health Care Related IT The Role of Health Care Related IT Advances In Advancing Public Health Advances In Advancing Public Health

SurveillanceSurveillance

John Lumpkin, M.D., M.P.H., John Lumpkin, M.D., M.P.H., Senior Vice President andSenior Vice President and

Director-Health Care GroupDirector-Health Care Group

The Robert Wood Johnson FoundationThe Robert Wood Johnson Foundation

EDIEDI

CLEARINGHOUSE

PAYER 1 PAYER 2

HEALTHDEPT

Medicare Reimbursements (Part A and B) in Medicare Reimbursements (Part A and B) in Relation to the National Average (2000)Relation to the National Average (2000)

More than 15% Above AverageMore than 15% Above Average (36)(36)00 - 15% Above Average- 15% Above Average (68)(68)00 - 15% Below Average- 15% Below Average (112)(112)More than 15% Below AverageMore than 15% Below Average (90)(90)Not PopulatedNot Populated

Jack WennbergDartmouthAtlas of Health Care

What does Greater Per Capita Spending What does Greater Per Capita Spending BUY?BUY?

not more effective or preference sensitive carenot more effective or preference sensitive care1.

00

1.00

1.00

1.18

0.98 1.04

1.38

0.97 1.03

1.66

1.00

0.99

0.00.0

0.40.4

0.80.8

1.21.2

1.61.6

2.02.0

Medicare ReimbursementsMedicare Reimbursements Effective CareEffective Care Preference-Sensitive CarePreference-Sensitive Care(Discretionary Surgery)(Discretionary Surgery)

Rat

io t

o L

ow

est

Sp

end

ing

Reg

ion

Rat

io t

o L

ow

est

Sp

end

ing

Reg

ion

More than 15% Below Average

0-15% Below Average

0-15% Above Average

More than 15% Above Average

Jack WennbergDartmouthAtlas of Health Care

Asthma: Outpatient Follow-upAsthma: Outpatient Follow-upAfter Acute EpisodesAfter Acute Episodes

• Core concept: Core concept: Outpatient follow-up Outpatient follow-up after either ER visit or after either ER visit or admissionadmission

• Children 5-17 years oldChildren 5-17 years old• Standard based on Standard based on

national expert panel national expert panel guidelinesguidelines

0

10

20

30

40

50

60

70

80

90

100

Follow-up Rate

White

African-American

Quality of Health Care in US??Quality of Health Care in US??

• Overall Care 54.9%

• Preventive 54.9%

• Acute 53.4%

• Chronic 56.1%

• History 43.4%

• Counseling or Ed 18.3%

• Immunization 65.7%

Elizabeth McGlynn, et al NEJM June 26, 2003 348:26

The focus must shift from blaming The focus must shift from blaming individuals for past errors to a focus on individuals for past errors to a focus on

preventing future errors by designing safety preventing future errors by designing safety into the systeminto the system

To Err is Human

- Institute of Medicine

Current practice Current practice depends upon the depends upon the

clinical decision-making clinical decision-making capacity and reliability capacity and reliability

of autonomous of autonomous individual practitioners, individual practitioners, for classes of problems for classes of problems that routinely exceeds that routinely exceeds the bounds of unaided the bounds of unaided

human cognitionhuman cognitionDaniel R. Masys, M.D.

2001 IOM Annual Meeting

“We have wonderful technology, but some grocery stores have better

technology than our hospitals and clinics.”

Secretary Tommy ThompsonChicago Medical School CommencementJune 7, 2002

Vision of the NHIIVision of the NHII

• The set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health.

• NOT a centralized database.• Connects distributed health information in

the framework of a secure network with strict confidentiality protections.

NHIINHII

Population Health

(Preparedness)

Healthcare ProviderPersonalHealth

Framework for Framework for PMRI (Patient Medical Record PMRI (Patient Medical Record

Information) StandardsInformation) Standards

InteroperabilityInteroperability

Data

Data

Quality

Quality

ComparabilityComparability

• More easily & accurately exchange PMRI between systems

• Better understand PMRI across systems

Objectives of PMRI StandardsObjectives of PMRI Standards

Inflamed Ear

? Rx

Overview of PMRI DimensionsOverview of PMRI Dimensions

Interoperability

Data

Quality

Comparability

HIPAAHIPAA

HL7 &

DICOM HL7 & ASTM

HL7

HL7

ASTM

& HL7

IEEE

PMRIPMRI

Laboratories

ASC

X12N &

NCPDP

NCPDP &

ASC X12N

NCPDP &

X12N

Radiology

Hospital

Pharmacy

Knowledge

bases

Physiological

monitors

Medical

devicesBedside

computer

Patient

Registration/

Admissions

Billing

Clinical

content

Orders

&

results

Community

Pharmacies

Pharmacy

Benefits Mgrs

Payers

HL7

HL7

&

ASTM

HL7

IEEE

(Adapted from Electronic Health Records: Changing the Vision, Eds. GF Murphy,MA Hanken, and KA Waters. Philadelphia: W. B. Saunders Company, 1999)

Interoperability StatusInteroperability Status

Overview of PMRI DimensionsOverview of PMRI Dimensions

Interoperability

Data

Quality

Comparability

Comparability Comparability IssuesIssues

• Comparability requires that the meaning of data is consistent when shared among different parties

Vocabulary Set of highly granular, specialized terms

ClassificationOrganization of related terms

Coderepresentation

of term

Terminology

Comparability StatusComparability Status

ConvergenceSNOMED RT/

NLM - UMLS

Message Specific Codes

• DICOM• NCPDP• IEEE• HL7*• X12N

Nursing Codes

• HHCC*

• NANDA*

• NIC*• NMMDS

• NOC*

• OMAHA*

• PCDS*• PNDS

Drug Codes

•

• *•

Diagnoses & Procedure Codes• Alternative Link*

• CDT-2*

• CPT-4*• HCPCS*

• ICD-9-CM/ICD-9-V3*

• ICD-10-CM*

• ICD-10- PCS

• ICIDH-2

Other Codes

•Health Language Center

•UMDNS (ECRI)*•DEEDS

•UPN (HIBCC)/UPC (UCC)

Clinically Specific Codes

• DSM*

• Gabrieli• LOINC*

• MEDCIN

• MedDRA

• SNOMED V3*

• NHS Clinical Terms*

The Health Informatics The Health Informatics PipelinePipeline

Foundation Foundation HIPAA StandardsHIPAA Standards

Financial &

Administrative

Interoperability

Comparability

Dat

a Q

ualit

y

Privacy &Security

Other StandardsOther Standards

• HL-7 EMR

• CHI

Standards Announced March 2003

1. LOINC: Laboratory Result Names2. HL7 Messaging Standards: Includes scheduling,

medical record/image management, patient administration, observation reporting, financial management, patient care

3. NCPDP: Includes retail pharmacy transactions4. IEEE 1073 Messaging Standards: Connectivity5. DICOM Messaging Standards: Includes Image

Information to Workstations

May 6, 2004

Lab Results Contents

Demographics

Units

Immunizations

Medications

Interventions and Procedures (A. Lab, B. Non-lab)

Diagnosis/Problem List

Anatomy/Physiology

Nursing

Billing/Financial

Medical Devices and Supplies

Encounters

Disability

Population Health

Text-Based Reports

History and Physical

Multimedia

Genes and Proteins

Chemicals

HHS Agencies with NHII HHS Agencies with NHII ResponsibilitiesResponsibilities

• AHRQ

• ASIRM

• ASPE

• CDC

• CMS

• Data Council

• FDA

• HRSA

• NCHS • NIH• NLM• OCR• OPHS

I always knew that Data was a I always knew that Data was a four letter word, four letter word,

I just never knew it was spelled I just never knew it was spelled

T-U-R-FT-U-R-F

Phil Lee, MD

Issues for the Development of the Issues for the Development of the NHIINHII

• Government RoleGovernment Role– HIPPA ApproachHIPPA Approach– CHI CHI – 800 pound Gorilla800 pound Gorilla– New IT CzarNew IT Czar

Architecture IssuesArchitecture Issues

• Options for structure– Repository based structure– Directory based structure

• National Databank

• Napster

• Systems of Systems

• Free floating peer to peer

PUBLIC HEALTH AND PUBLIC HEALTH AND MEDICAL PRACTICE BOTH MEDICAL PRACTICE BOTH USE THE SAME DATA, WE USE THE SAME DATA, WE

JUST LOOK AT IT JUST LOOK AT IT DIFFERENTLYDIFFERENTLY

- CHRISTINE GEBBIE

Recommendations* to the Secretary of Recommendations* to the Secretary of HHS and DHHS agenciesHHS and DHHS agencies

Recommendation 1. Appoint a national commission to develop a framework for state public health law reform.

Recommendation 5. Initiate a broad-based national dialogue, led by a national commission convened by the Secretary of HHS, to explore perspectives on workforce credentialing, and to outline next steps based on decisions reached.

Recommendation 7. Facilitate the development and implementation of the National Health Information Infrastructure (NHII).

Committee on Assuring the Health of the Public in the 21st Century - 2002

HL7 &

DICOM HL7 & ASTM

HL7

HL7

ASTM

& HL7

IEEE

PMRIPMRI

Laboratories

ASC

X12N &

NCPDP

NCPDP &

ASC X12N

NCPDP &

X12N

Radiology

Hospital

Pharmacy

Knowledge

bases

Physiological

monitors

Medical

devicesBedside

computer

Patient

Registration/

Admissions

Billing

Clinical

content

Orders

&

results

Community

Pharmacies

Pharmacy

Benefits Mgrs

Payers

HL7

HL7

&

ASTM

HL7

IEEE

(Adapted from Electronic Health Records: Changing the Vision, Eds. GF Murphy,MA Hanken, and KA Waters. Philadelphia: W. B. Saunders Company, 1999)

Interoperability StatusInteroperability Status

Issues for Health CareIssues for Health Care

• HIPAA

• Cost of Reporting– Time is money– Hassle factor– What’s in it for me?

• Reporting as a Quality Measure?

Arthur C. Clarke LawsArthur C. Clarke Laws

Third Law:

"Any sufficiently advanced technology is indistinguishable from magic."

First Wave of Public Health First Wave of Public Health System DevelopmentSystem Development

• State based Systems– Metabolic Disease

• Federal Systems for State Usage– HIV/AIDS Registry 1987

• In the beginning we saw that it was good...

Second Wave of Public Health Second Wave of Public Health Information System DevelopmentInformation System Development

• State Developed Systems– Integrated

• Cornerstone – 1993- Illinois – WIC

– Immunization

– Case Management

– Well Child

– Stand alone• Immunization registries

Third Wave of Public Health Information Third Wave of Public Health Information System DevelopmentSystem Development

• Federal Centric– State developed prototype – Installed in many states

• State Centric– System Development by Consortium of States

• Web enabled Immunization Registry

• Reuse Model

• ASP Model

An Enterprise View,An Enterprise View,Defined Collaboratively,Defined Collaboratively,to build organizational to build organizational

capability and data capability and data interoperability:interoperability:

A Case StudyA Case Study