electronic health records: what’s in the pot of gold at the end of the rainbow ?
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Electronic Health Records:
What’s in the pot of gold at the end of the rainbow ?
Neil S. Calman, MD
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The Goals….
Improve Quality, Safety, Efficiency and Reduce Health Disparities
Increase Engagement of Patients and Families
Improve Care Coordination
Improve Population and Public Health
Ensure Privacy and Security Protections of Personal Health Information
3
! ! !
ClinicalDecision
Support 2003
Progression of HIT at the Institute
EHR/PMS Implementation
2002
HIE/ Patient Portal
2008
Quality Reporting/ Improvement 2004
EHR = Electronic Health Record
PMS = Practice Management System
HIE = Health Information Exchange
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Supporting population based care
1
5
Major Congenital Malformations
after First-Trimester
Exposure to ACE Inhibitors
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Colon Cancer Risk Scoring
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Linking to the Nation’s public health surveillance system
2
8
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Release
Nu
mb
er o
f C
ases
Symptom Onset Severe Illness
Days
The Benefit of Early Detection of Syndromes
t
9
Single patient visit yields complex EHR data
• Patient Address• Race / Age / Gender• Medical history
• Provider Location• Reason for visit• Problem list
• Temperature• Height/weight• Respirations
• Procedures• Medications• Lab results• Diagnoses
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EHR Fever
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
7/8/03 8/8/03 9/8/03 10/8/03 11/8/03 12/8/03 1/8/04 2/8/04 3/8/04 4/8/04 5/8/04 6/8/04
Pe
rce
nta
ge
of
fev
er/
flu
ch
ief
co
mp
lain
ts
0.000
0.010
0.020
0.030
0.040
0.050
0.060
Pe
rce
nta
ge
of
me
as
ure
d t
em
pe
ratu
resBlue = ER “flu/fever”
Purple = EHR Fever >100 F
Red = Flu “A” isolates
Violet = Flu “B” isolates
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0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
7/8/03 8/8/03 9/8/03 10/8/03 11/8/03 12/8/03 1/8/04 2/8/04 3/8/04 4/8/04 5/8/04 6/8/04
Perc
enta
ge o
f Fev
Flu
chie
f com
plai
nts
0.000
0.005
0.010
0.015
0.020
0.025
Perc
enta
ge o
f com
bina
tion
synd
rom
e
Fever AND respiratory syndrome
Blue = ER “flu/fever”
Brown = EHR T≥ 100o and
Respiratory Syndrome
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Institute patient fevers peaked 13 days before ER visits for Fever and Flu – this indicates that health center data may be the first “signal” of an impending epidemic.
Patients of the Institute for Urban Family Health
Institute fever data responded to Flu B outbreak-ED data did not
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14
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Bringing public health information to the point of
care in real time
3
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Practice Alert in EHR for this center only if patient presents with cough – matched to Legionella order set to assist provider in Dx and Tx
DOH sends alert to community re Legionella cases in Parkchester community in the Bronx
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18
19
20
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Developing Clinical Decision Supports
over a Broad Range of Measures
4
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Clinical Decision Support – Impact on Vaccine Administration in Adults
23
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10 Take New York Indicators1. Have a Regular Doctor or Other Health Care
Provider2. Be Tobacco-Free3. Keep Your Heart Healthy4. Know Your HIV Status5. Get Help for Depression6. Live Free of Dependence on Alcohol and Drugs7. Get Checked for Cancer8. Get the Immunizations You Need9. Make Your Home Safe and Healthy10. Have a Healthy Baby
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Developing the EHR to monitor quality of care across practice sites
5
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Patients Seen at Least Once by Their Primary Care Provider
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Men >35; Women>45 Who have had their cholesterol tested
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Men >35; Women>45 Who have had their cholesterol tested
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Depression Screen with PHQ2
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Depression Screen with PHQ2
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PARKCHESTER DEPRESSION SCREENING RATE
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PARKCHESTER
NURSING
PERSONNEL SHORTAGE
NURSING SHORTAGE RESOLVED
STEPPED UP VIGILANCE TO BPA ADHERENCE
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South Campus Depression Screening
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Amsterdam
East 13th
Homeless
Mount Hope
Parkchester
Phillips
Sidney Hillman
Urban Horizons
Walton
Phase II spread at all sites other than SHHC
E13th PHQ2 CQI Project starts
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Recorded Smoking History
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Recorded Smoking History
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Pneumococcal Vaccine >65yrs old
36
Pneumococcal Vaccine >65yrs old
37
38
39
Using EHR data to determine primary care
practices that are associated with
improved outcomes
6
40
Provider Nutritionist Referral Rate vs. Pts Average HgBA1c
6.5
7
7.5
8
8.5
9
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%
Rate of Nutrition Referral
Mo
st
Re
ce
nt
Hg
bA
1C
22
12
1
9
0.9
41
Using EHR data to elucidate and help
eliminate racial disparities in health
outcomes
7
42
Last Hemoglobin A1c by Race
White 7.03
n=423
Black 7.44
n=2122
Latino 7.86
n=1555
Asian 7.12n=76
6.6
6.8
7
7.2
7.4
7.6
7.8
8
HgbA1c
43
0
10
20
30
40
50
60
70
80
90
Insulin/SensAgent %
1 HgbA1c % 2 HgbA1c % LDL test %
White
Black
Latino
Asian
44
Reductions in HgbA1c with Treatment by Race /Language
6.5
7
7.5
8
8.5
White 7.23 6.95
Black 7.80 7.44
Latino-Eng 8.02 7.75
Latino- Span 8.12 7.81
Other 7.82 7.48
1st HgbA1C Most Recent
45
Five-year Cancer (all sites) Survival Rate
SOURCE: CDC/NCHS, Health, United States, 2004
30
3540
4550
55
6065
70
1970 1975 1980 1985 1990 1995 2000Year
Pe
rce
nt
Su
rviv
al
Ra
te White
Black
46
Life Expectancy at Birth
60.0
65.0
70.0
75.0
80.0
1950 1960 1970 1980 1990 2000Year
Lif
e E
xp
ecta
ncy (
Years
)
White
Black
SOURCE: CDC/NCHS, Health, United States, 2004
47
Infant Mortality Rates
0
5
10
15
20
25
30
1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020
Year
Infa
nt
dea
ths
per
1,0
00 li
ve
bir
ths
White
Black
SOURCE: CDC/NCHS, Health, United States, 2004
48
Age-adjusted death rates for diseases of the heart per 100,000 males
0.0
100.0
200.0
300.0
400.0
500.0
600.0
Year
De
ath
Ra
tes
pe
r 1
00
,00
0 M
ale
s
White
Black
SOURCE: CDC/NCHS, Health, United States, 2004
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Dissemination of Results; Credits
50
Authored Publications
• Calman NS, Kitson K, Hauser D “Using Health Information Technology to Improve Health Quality and Safety in Community Health Centers”. Journal of Progress in Community Health Partnerships: Research Education and Action.1(1):83-88. Spring 2007
• Calman, NS, Golub M, Kitson K, Ruddock C. Electronic Health Records: The Use of Technology to Eliminate Racial Disparities in Health Outcomes. In: Medical Informatics: An Executive Primer. Health Information and Management Systems Society, Chicago, IL. Kenneth Ong, MD, Editor. January 2007.
51
Authored Publications
• Sengupta S, Calman NS, Hripcsak G. A Model for Expanded Public Health Reporting in the Context of HIPAA. J. Am. Med. Inform. Assoc. 25 June 2008
52
Our work has been featured in a number of publications by others and has been used as the foundation for others to build upon
53
Commonwealth Fund
“Quality Matters”
May 2006
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Miller RH and Ward CE
Health Affairs Jan-Feb 2007
55
Awards
2007
Public Health Award
HIMSS Physician
IT Leadership
Award
2005
Partner in NYCDOH
CDC Center of Excellence
in Public Health
Informatics
Non-profitExcellence Award 2008
Technology and Focus on Mission
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