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

PERCENT OF CANCER PATIENTS ADMITTED TO ICU DURING THE LAST MONTH OF LIFE, 2010

Total Reimbursements(Part A + Part B)

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

Domains and Items for Patient Health Update

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