Big Data: Compiling Data Across EHRs · 2020-02-11 · DARTNet (Distributed Ambulatory Research in...
Transcript of Big Data: Compiling Data Across EHRs · 2020-02-11 · DARTNet (Distributed Ambulatory Research in...
Big Data: Compiling Data
Across EHRsTim Burdick MD MBA MSc
Assistant Professor
Geisel School of Medicine
Community and Family Medicine
Biomedical Data Science
The Dartmouth Institute
Dartmouth-Hitchcock Health
Primary Care Clinic
Heater Road
Lebanon, NH
Nothing to disclose.
Forget the stethoscope, kid. It’s all about EHR data!
Does he expect
me to document
the exam in the
computer?!
Where are we going today?
Why digitize medical records?
EHRs under the hood
Linking data in PBRNs
Projects in PBRNs
The future of truly big data
Discussion
Always start with the WHY?
Why make information electronic?
Carpenter & Canaday (2004)
ENVIRONMENT
• This is our patient, Fred
• Measure; create structure; codify
DATA
• Fred: HA1C = 7.8;BMI = 38
• Look for patterns; understand relationships
INFORMATION
• Fred has Type 2 diabetes caused by his obesity
• Understand patterns; find predictability
KNOWLEDGE
• Patients w/ DM have lower quality life years & cost more
• Apply patterns; understand principles/goals
WISDOM
• DM guidelines improve Quadruple Aim outcomes
• Use compassion; apply values
VISION
• Effective treatment of patients with DM is good for all
CONTEXT/
RULES
MEANING/
MODEL
INSIGHT
VALUE/
PURPOSE
INDEX
Environment
Data
Information
Knowledge
Wisdom
Vision
PAST
FUTURE
Environment to Vision
The Bad and The Ugly
ANNALS OF MEDICINE NOVEMBER 12, 2018 ISSUE
WHY DOCTORS HATE
THEIR COMPUTERSDigitization promises to make medical care easier and
more efficient. But are screens coming between doctors
and patients?
By Atul Gawande
And the Good
https://www.opennotes.org/
Choosing Wisely Clinical Decision Support Adherence and
Associated Inpatient Outcomes
26,500 inpatient encounter measured adherence to CDS
- Cost of care 7% lower
- Length of stay 6% lower
Millions of patients worldwide
- 83% report feeling more more in control of their health
- 25% report a correction to their medical record
Heekin et al. Am J Manag Care. 2018;24(8):361-366
In the Beginning there was...who is this man?
Lawrence L. Weed MD
UVM College of Medicine
Professor of Medicine, and Community Medicine,
Director, PROMIS Laboratory
(Problem Oriented Medical Information System)
Touchscreen of the
Megadata Terminal.
c. 1977
Grand Isle Clinic, VT – PROMIS (c. 1979)
Microwave dish
Health Insurance Portability and Accountability Act (1996)
Title II: Administrative Simplification Provisions
● Implemented 2005 for claims submissions
● Standard electronic codes for encounters (ICD-9, ICD-10)
● Standard data transmission methods
● Security requirements
● National Provider Identification (NPI)
HIPAA, not HIPPA (a female hippo?)
What drove $36 billion dollar investment in health IT?
The US Housing Market
And the US economy generally
American Reinvestment & Recovery Act (ARRA) 2009
Healthcare Information Technology for Econonomic and Clinical Health (HITECH)
● Federal government reimburses hospitals and physicians for EHR adoption
● Must demonstrate “Meaningful Use” of the EHR
● Incremental requirements each year
● Clicking for dollars
Standards
● ICD – International Classification of Diseases (1900)
● SNOMED CT – Systematized Nomenclature of
Medicine Clinical Terms (1965)
● LOINC – Logical Observation Identifiers Names and
Codes (1994)
● RxNorm (2001)
RxNorm for codeine 30mg tablet:
SNOMED for scalding of the left index finger
C0123456|Codeine|Codeine Phosphate|Codeine|P|30|MG|Component
Common Data Models (CDM)
Enter heart rate in EHR user interface
EHR stores in database tables
Database Extraction, Transformation, Load (ETL)
• identify what data to pull out of EHR tables
• map to Observational Medical Outcomes Project
(OMOP) data model
• merge data from multiple EHR into combine database
with CDM
MRN VS_Date VS_time VS_measure_source VS_value
34823948-1 2020_01_24 0819 HR_monitor 92
40294820-3 2019_11_12 2354 SBP_left_arm 135
93092835-7 2018_07_15 1343 DBP_right_arm 82
83458230-7 2017_10_28 1005 Ox_Sat_finger 91
00299128-4 2019_08_01 1739 wt_kg_bed 78
MRN Name_Last Name_First DOB Zip_Home
83458230-7 Flintstone Fred 457_BC 99731
34823948-1 Flintstone Wilma 462_BC 99731
93092835-7 Burdick Tim 1981 03755
Functional Assessments
- Standardization
- Paper forms
- Manual data extraction & entry
- Subsample of patients or charts
- Data sizes in the hundreds
- Time-intensive
Dartmouth Coop
Charts
Then
Dartmouth Coop
Charts
Now
LOINC codes
● Formerly Oregon Community Health Information Network
● 1 shared EHR (Epic) since 2000
● 500+ organization partners
○ > 100 FQHCs
● 47 states
● >10,000 providers
● > 500,000 unique patients per month
● >400 staff in 35 states
● Teach and lead clinical quality improvement to member organizations
● $53 Million in external research dollars
● Hundreds of peer-review publications in top journals
PCORI CDRNs● 9 clinical research data networks
● Regional aggregation of core data from
many EHR systems
● EHR, Claims, Social Determinants,
Geocoded, Patient Reported Outcomes,
Insurance status, pharmacy dispense, test
results, immunization registries
pcornet: meta-network
66 million patients
550 million encounters
6 billion lab results
1 billion prescription dispenses
ADVANCE CDRN
- OCHIN-affiliated clinics
- Fenway Health clinics
- Oregon Health & Science University clinics
pcornet projects
● Do antibiotics in early childhood
increase risk of obesity?
○ 700,000 children
○ 10-year longitudinal study
● Sleeve gastrectomy is safer than
Roux-en-Y gastric bypass (RYGB)
○ 33,000 patients
○ 5-year study
States with PCORI Rare Disease Project leads
DARTNet (Distributed Ambulatory Research in Therapeutics Network)
Started 2007 (AAFP, Univ Colorado Family
Medicine, AHRQ, private tech company)
Developed ELT tools for any EHR
Map data to OMOP CDM
12 PBRNs contracted services
3 rural: WWAMI, Appalachian, Upstate NY
Value-add services
Quality improvement analytics and reports
Meaningful Use /PIP registries
● 5 million patients
● 12 million encounter per year
● 5 billion data points
DARTNet Academic Partners
•Northwestern University•Ohio State University•University of Alabama at Birmingham•University at Buffalo•University of California San Diego•University of Colorado Denver•University of Kansas•University of Minnesota•University of Texas San Antonio•University of Vermont•University of Washington
Academic Partners
NIH Clinical Translational Science Award centers
(~ Dartmouth Synergy)
© Epic Systems, Verona, WI
Single Alcohol Screening Question
● 77 weeks of data
● 200+ clinics
● 95,537 screenings
● 24.5 million visits
● Now you have data
about alcohol use
patterns across
large population
Correlate w use of
services, chronic
disease, mental
health, etc
Big, Really Big Data
Genomics
Imaging studies (MR, pathology)
Social Determinants
Exposome
Proteome
Microbiome genetics
Wearables and implantables
Discussion
What EHRs are you using? (Poll)
eCW? Epic? athenahealth? Allscripts? Amazing Charts? Greenway?
NextGen? Cerner? Other?
How are you leveraging data for quality improvement in your practice?
Research studies using your practice data from EHR?
What is keeping you from using your data more effectively?