collecting information on behavioral and social factors in the ehr robert m. kaplan associate...
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Collecting Information on Behavioral and Social Factors in the EHR
Robert M. KaplanAssociate Director , NIH Office of the Director
Director Office of Behavioral and Social Sciences ResearchCommittee for Social & Behavioral Domains for Electronic Health Records
September 24, 2013
“Science in pursuit of fundamental knowledge about the nature and behavior of living systemsand the application of that knowledge to enhance health, lengthen life and reduce illness and disability.”
...
NIH: Steward of Medical and Behavioral Research for the Nation
U.S. Health in International Perspective:
Shorter Lives, Poorer Health
Sponsor BriefingNational Institutes of HealthJanuary 8, 2013Steven H. Woolf, MD, MPHChair, Panel on Understanding Cross-National Health DifferencesAmong High-Income Countries
Sponsor: National Institutes of Health
National Academies Press © 2013
17 Peer Comparison Countries
• Australia• Austria• Canada• Denmark• Finland• France• Germany• Italy• Japan
• Norway• Portugal• Spain• Sweden• Switzerland• The Netherlands• United Kingdom• United States
Years of Life Lost Before Age 50, 2006-2008
Males Females
• US male and female newborns can expect to lose about 1.4 years and 0.8 years of life, respectively, before age 50.
• The US losses before age 50 are double those of Sweden, the best performing country.
Probability of Survival to Age 50 in 21 High-Income Countries, 1980-2006
Males Females
For decades, American youth have been less likely to survive to age 50 than people in other rich nations.
Change In Female Mortality Rates From 1992–96 To 2002–06 In US Counties.
• ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.Kindig D A , and Cheng E R Health Aff 2013;32:451-458
Bottom Up: McGinnis and FoegeJAMA 1993, 270, 2207.
• Tallies of available information about the presence or absence of a factor in association with a given outcome (eg, whether or not a driver in a motor vehicle fatality had a blood alcohol concentration above acertain level).
• Population-attributable risk calculations were used to arrive at estimates based on determinations of the relative risk for a particular health outcome of a population exposed to a specified health risk
Date of download: 9/23/2013Copyright © 2012 American Medical Association.
All rights reserved.
From: The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors
JAMA. 2013;310(6):591-608. doi:10.1001/jama.2013.13805
Number of Deaths and Percentage of Disability-Adjusted Life-Years Related to the 17 Leading Risk Factors in the United States in 2010 for Both Sexes Combined
Figure Legend:
• Fineberg critique– Poor representation of
socioeconomic factors– Sum of the effects of risk
factors exceeds 100%– Method works through
diagnosis rather than total mortality
JAMA August 14, 2013 Volume 310, Number 6
Top Down
Derived from large data bases using linear models• Actuarial Studies• Large Epidemiologic Cohorts
Example, logistic regression analysis of all cause mortality in the Framingham Heart Study
What Are the Underlying Causes of Death in the United States?From Schroeder, N Engl J Med 2007; 357:1221-1228
• A variety of different analyses consider the factors underlying the most common cause of death.
• Across studies, the high estimate for the benefits of health care is 20%, with most studies estimating around 10%.
Determinants of Heath Outcome
Deaths Attributable to Behavioral Factors: Adapted from Murray 2013
ATTRIBUTABLE TO BEHAVIORAL FACTORS
NOT ATTRIBUTABLE TO BEHAVIORAL FACTORS
Need for Research Studies
♦ Most studies use their own measures, often unknown characteristics and quite different measures for same construct
♦ Without standard or more harmonized measures, difficult to do reviews, syntheses, compare across studies
In the billions of dollars spent on EHRs in last several years, one thing is missing: Patient-Reported Measures
Advent of patient-centered medical home and “meaningful use” of EHRs
Impossible to provide patient-centered care if no patient measures, goals, preferences, concerns collected
With recent advances in measurement, meaningful use incentives, time is right
Need for Primary Care
Why Use IOM?• In order to achieve harmonization, we must come to
consensus on– Which domains should be measured
• Must develop criteria for identifying domains– Examine both data elements and mechanisms for
data collection using evidence from the research as well as input from key stakeholders
• EHR vendors; • government, • health and technology agencies;• the private health care industry
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