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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
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EDIEDI
CLEARINGHOUSE
PAYER 1 PAYER 2
HEALTHDEPT
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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
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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
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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
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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
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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
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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
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“We have wonderful technology, but some grocery stores have better
technology than our hospitals and clinics.”
Secretary Tommy ThompsonChicago Medical School CommencementJune 7, 2002
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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.
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NHIINHII
Population Health
(Preparedness)
Healthcare ProviderPersonalHealth
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Framework for Framework for PMRI (Patient Medical Record PMRI (Patient Medical Record
Information) StandardsInformation) Standards
InteroperabilityInteroperability
Data
Data
Quality
Quality
ComparabilityComparability
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• More easily & accurately exchange PMRI between systems
• Better understand PMRI across systems
Objectives of PMRI StandardsObjectives of PMRI Standards
Inflamed Ear
? Rx
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Overview of PMRI DimensionsOverview of PMRI Dimensions
Interoperability
Data
Quality
Comparability
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HIPAAHIPAA
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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
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Overview of PMRI DimensionsOverview of PMRI Dimensions
Interoperability
Data
Quality
Comparability
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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
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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*
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The Health Informatics The Health Informatics PipelinePipeline
Foundation Foundation HIPAA StandardsHIPAA Standards
Financial &
Administrative
Interoperability
Comparability
Dat
a Q
ualit
y
Privacy &Security
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Other StandardsOther Standards
• HL-7 EMR
• CHI
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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
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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
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HHS Agencies with NHII HHS Agencies with NHII ResponsibilitiesResponsibilities
• AHRQ
• ASIRM
• ASPE
• CDC
• CMS
• Data Council
• FDA
• HRSA
• NCHS • NIH• NLM• OCR• OPHS
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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
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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
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Architecture IssuesArchitecture Issues
• Options for structure– Repository based structure– Directory based structure
• National Databank
• Napster
• Systems of Systems
• Free floating peer to peer
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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
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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
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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
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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?
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Arthur C. Clarke LawsArthur C. Clarke Laws
Third Law:
"Any sufficiently advanced technology is indistinguishable from magic."
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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...
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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
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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
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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
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