Integrating Public Health into the Medical Information Economy

Leslie Lenert, MD, MS

What informatics Isn’t…

Fundamental Theorem of Informatics

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Corollaries of the Theorem

Epistemology and Informatics

Figure: http://vannevar.blogspot.com/2009/05/experience-karl-poppers-three-worlds.htmlReference: Objective Knowledge: An Evolutionary Approach

Software as Objective Knowledge

Subjectivereality of

physicians

Subjectivereality of

physicians

Computerartifacts tomanage

physicians’ world

Computerartifacts tomanage

physicians’ world

Physical World

Capturing Knowledge and Translating Knowledge to Action

Subjectivereality of

physicians

Subjectivereality of

physicians

Computerartifacts tomanage

physicians’ world

Computerartifacts tomanage

physicians’ world

Subjectivereality of

public health

officials

Subjectivereality of

public health

officials

Computerartifacts tomanage

populationhealth

Computerartifacts tomanage

populationhealth

Informatics

Physical World

Informatics and the Information Supply Chain

CDC

State, County, and Local Health Departments

Laboratories Practitioners

InformationSupply Chain

=Information

Tax

Meaningful Use for Public Heath

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Meaningful use requirements parallel current information supply chain strategies (aka “paving the cow path”)

Utility comes from use of Systems thatControl Problems

ELR

Public Health Event

Female of child bearing age visits doctor and is tested for hepatitis

Positive test result for hepatitis B surface antigen

NEDSS Base System (NBS)

ClinicalLab

Vital Statistics

ImmunizationRegistry

Determine if the female has given birth in the recent past

Hepatitis panel ordered

If the infant becomes infected with hepatitis B, case data can be sent back to the surveillance system for reporting, eliminating duplicate data

entry

Alabama State DOH

Example: Alabama MCH system to help reduce hepatitis B virus transmission from pregnant women to their newborns

ELR automatically routed based on parameters:-Hepatitis B-Female of child bearing age

Perinatal Hepatitis B Registry

Maternal and Child Health Program

Determine if infant has received HBV immuni-zation

Case reporting functionality in NBS 3.0. Release date fall ‘09

Other Registries

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An i-commerce approach to syndromic surveillance and to outbreak control

“i-commerce: exchange of information with a trading partner to mutual benefit”

Linkage with the Clinical Care System

States/CDC monitoring public health identify a

Salmonella outbreak

Patient presents to clinic exhibiting gastrointestinal

symptoms

How can providers be alerted of

outbreaks relevant to their patient at the

time of care

State Public Health

Local Public Health

Pu

blic

He

alt

h A

ge

ncy

Med

ical

Co

mm

un

ity

States/CDC monitoring public health discover Salmonella outbreak

Salmonella Alert Identified/Coded(SNOMED, LOINC)

Salmonella Message Created

Alerting TransportSystem Sends Message

Case Archive

Salmonella message sits on a standalone knowledge repository

or on a PH grid.

Knowledge Repository

Provi ders Desktop

*Public Health Alert*Salmonella detected..

Infobutton RequestProviders Seeing

Patients

As part of their workflow, providers poll for messages when seeing patients and

click the info button for more detail.

Hospital HIE COEMD

OfficeCitizen

Intl Healthcare

Facility

EHR+OpenMRS

PHRWWW

i Context based request using standardized, anonymous case data.· User context· User action· Patient record content

EMR decision support algorithms envoked.

Rule based PH profile matching

Rule Based Alerts

Salmonella:JurisdictionStart date

Case definitionRecommendation

Rule Based Public Health alert information to CIS providing decision support objects (text for display, order sets, etc)

An extension of the knowledge

repository, alerts will be stored to

assist in biosurveillance

EHR Alerting Concept Diagram

Knowledge Repository Content and Rules

Salmonella PH Alert MessageMessage ID #: 2345643

As of 9/20/08, 100 persons with Salmonella have been reported to CDC from two states, Ohio and Pennsylvania. Onset dates range from 9/21/ 08 – 9/30/08. Illness possibly linked to chicken wings.

Symptoms:DiarrheaFeverAbdominal Cramps

Patient Demographics:Ages: allGender: allRace: all

Jurisdiction:Zip codes: 30308, 30331, 32098

45693, 42532, 44523

Recommendations:Diagnosis by culture of a stool sampleReport positive findings to local health deptTreatment: Fluids via ORS, Pedialyte, GatoradeAntibiotic treatment for severe cases onlyPrevention: Thoroughly wash and cook foods

Date of last update: 10/1/08 Expiration date: 11/1/08

EMR Anonymous Patient Profile Message

Chief Complaint(s):DiarrheaAbdominal Cramps

Patient Demographics:Age: 25Gender: MaleRace: Caucasian

Jurisdiction:Zip code: 30331

MATCH

MATCH

MATCHMATCH

MATCH

MATCH

EHR Anonymous Patient Profile Message

Public Health Alert on the Clinician Desktop

Benefits of Systems Approach

• Syndromic surveillance data collected as a byproduct of clinical care integration

• Physician behavior altered at the point of care

• Sustainability achieved not by incentives or by “information taxes” but by mutual benefit (“i-commerce”)

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Replace the alert rules with registries

• Send identifier at ED visit or other medical care visit and receive:– Public health issues (MDX or XDR TB;

Contact tracing for investigation)

– Physicians with critical information for patients (“lost to follow up”)

– Diabetes and other chronic diseases with control problems

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Other types of registries

• Prescription data– Opiate abuse

– Cognitive impairing drugs and accidental overdose prevention

– Medication resolution and drug–drug interactions

• Preventative services reminders

• Critical diagnostic tests

Some registries will require patientconsent

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Meaningful Use vs. Meaningfully Useful

• PH connection “optional”

• Data forwarded without system connection

• Sustainability an issue of law

• PH connection adds value

• Data forwarded returns information

• Sustained by mutual benefit

18

MU as conceived MU as System

Public Health Challenge

• Sufficient data at the local level to measure health for neighborhoods and communities– BFRSS: survey methods too costly

– All payer database: no denominator

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Meaningful Use and Quality Reporting

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EHR

attestation

CMS

Meaningful use requires reporting of summary data on selected quality measures toCMS

Clinical Quality Measures and Public Health

• Clinical Quality– BP measurement

– Tobacco use assessment and intervention

– Adult weight screening and follow up

Denominator based:

% patients seen, % with problem, % meeting guideline

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ClinicalDatabase

Data setcache

PeriodicExtract ofqualitydata sets

Result #1

DeliveryService

PublicationService Result #2

Result #3

Firewall

Registry of data sources

Quality reportcard for region

ClinicalDatabase

Data setcache

PeriodicExtract ofqualitydata sets

Result #1

DeliveryService

PublicationService Result #2

Result #3

Registry of data sources

Geomapwith rates

of servicesoverall proviers

Summary Data

• Geographic Interoperable Population Summary Exchange (GIPSE) format

• Strengths: – builds on quality reporting

– Detailed data on geo regions

– Secure and Low Risk (no personal health data transmitted)

• Weakness– De duplication function needed

– Further investigation requires individual data