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The Regenstrief Experience:The Regenstrief Experience:Integrating Data Repositories Integrating Data Repositories and Real World Examples of and Real World Examples of

Passing “Data Value” to Passing “Data Value” to Caregivers: ImmunizationsCaregivers: Immunizations

Paul Biondich, MD, MSPaul Biondich, MD, MSChildren’s Health Services ResearchChildren’s Health Services ResearchRegenstrief Institute InvestigatorRegenstrief Institute Investigator

What We’ll CoverWhat We’ll Cover

The Regenstrief Indiana Network for The Regenstrief Indiana Network for Patient Care (INPC) Patient Care (INPC) –– backgroundbackgroundCreating Interfaces with CHIRP and Creating Interfaces with CHIRP and the Importance of Standardsthe Importance of StandardsSpecific Examples of Integrating / Specific Examples of Integrating / Enhancing the Clinical Experience Enhancing the Clinical Experience Using These DataUsing These DataImplementation / Integration PearlsImplementation / Integration Pearls

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INPC INPC -- Humble Beginnings Humble Beginnings

In health care settings, information comes from In health care settings, information comes from a host of fragmented sources (lab, radiology, a host of fragmented sources (lab, radiology, registries, etc.)registries, etc.)Regenstrief tasked in 1972 to “stitch” these Regenstrief tasked in 1972 to “stitch” these sources together sources together --> the Regenstrief Medical > the Regenstrief Medical Record System (RMRS/Record System (RMRS/WishardWishard) ) In 1994, began stitching together information In 1994, began stitching together information across institutions (INPC/Indianapolis)across institutions (INPC/Indianapolis)In 2003, working towards stitching the state In 2003, working towards stitching the state together (INPC/Indiana)together (INPC/Indiana)

Indiana Network for Patient Care Indiana Network for Patient Care (INPC)(INPC)

Up and running for more than 9 yearsUp and running for more than 9 yearsStarted with a modest goal (Emergency Started with a modest goal (Emergency Care)Care)Extended by adding projects one step at a Extended by adding projects one step at a timetimeFocus on clinical and public health issues, Focus on clinical and public health issues, particularly electronic laboratory reportingparticularly electronic laboratory reportingWe serve as the “Data Switzerland” for the We serve as the “Data Switzerland” for the city of Indianapolis and the statecity of Indianapolis and the state

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INPC INPC –– Participants Participants

Includes 11 hospitals from the 5 major Includes 11 hospitals from the 5 major Indianapolis hospital systems (95% of nonIndianapolis hospital systems (95% of non--office care)office care)Includes all four homeless care systemsIncludes all four homeless care systemsIncludes county and state public health Includes county and state public health departmentsdepartmentsMany outpatient practicesMany outpatient practicesBoth major cardiologyBoth major cardiologyreferral centersreferral centers

INPC hospital participantsINPC hospital participants

Health DepartmentPractice/ClinicHospital

LabCorpLabCorp

QuestQuest

MCHDMCHD

Rx dataRx data

In p

rogr

ess

Heart Center of Indiana

The Indiana Heart Hospital

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A “Big” EMRA “Big” EMRIn the system:In the system:–– 15 million orders15 million orders–– 300 million coded results300 million coded results–– 5.5 million dictated reports5.5 million dictated reports–– 8.8 million radiology reports8.8 million radiology reports–– 25 million prescriptions25 million prescriptions–– 400,000 EKG tracings400,000 EKG tracings–– 2.3 TB radiology images2.3 TB radiology images

Added Per Year:Added Per Year:–– 600,000 ambulatory encounters600,000 ambulatory encounters–– 50,000 inpatient encounters50,000 inpatient encounters

Added daily:– 40 GB image data

Present Work/CommitmentsPresent Work/Commitments

Indianapolis HospitalsIndianapolis Hospitals–– All Admission/ All Admission/

Discharge SummariesDischarge Summaries–– All Operative NotesAll Operative Notes–– All Radiology ReportsAll Radiology Reports–– All Pathology ReportsAll Pathology Reports–– Inpatient MedicationsInpatient Medications

StatewideStatewide–– Tumor Registry DataTumor Registry Data–– Blood Lead DataBlood Lead Data–– ImmunizationsImmunizations–– Newborn ScreeningNewborn Screening–– Vital StatisticsVital Statistics–– Chief ComplaintsChief Complaints

All data is meant to be both received and sent by design

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Importance of StandardsImportance of Standards

The sine qua non for all of this workThe sine qua non for all of this workHL7HL7 is the protocol in which we both is the protocol in which we both receive and export all clinical datareceive and export all clinical dataLOINCLOINC provides us with standard codes provides us with standard codes that define content of each delivered HL7 that define content of each delivered HL7 message..message..–– Protects the same data within two institutions Protects the same data within two institutions

from being labeled different thingsfrom being labeled different things–– DTAP DTAP ImmunImmun vs. DTAP Shot vs. DTAPvs. DTAP Shot vs. DTAP

CHIRP / INPC InterfaceCHIRP / INPC Interface

Bidirectional HL7 interface using the Bidirectional HL7 interface using the immunization standards published by the immunization standards published by the CDCCDCWe will share lead and other “value We will share lead and other “value added” elements as desiredadded” elements as desiredThey will share immunization data with usThey will share immunization data with usNightly batch processNightly batch processImportance of Importance of CHIRP’sCHIRP’s interfaceinterface

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INPC InfrastructureINPC Infrastructure

HL7 Message

Map Code to LOINC

Standardized Institutional Vault

Institutional Source

Network TopologyNetwork Topology

7 T1 Lines

7 T1 Lines

T1T1

T1

T1

T1T1

T1T1T1T1

T1T1

9 Tele Lines

9 Tele Lines

2 Tele Lines

2 Tele Lines

2 ISDN Lines2 ISDN Lines

9 Tele Lines9 Tele Lines

St. VincentSt. Vincent

ShalomShalomWellness andWellness andRoberts ParksRoberts Parks

St. FrancisSt. Francis

St. FrancisSt. FrancisSouthSouth

CommunityCommunitySouthSouth

St. VincentSt. VincentCarmelCarmel

2 Tele Lines

2 Tele Lines

GennesaretGennesaretHomelessHomeless2 clinics2 clinicsMed StudentMed Student

VolunteerVolunteer2 clinics2 clinics

VPNVPN

10 MB 10 MB

Ethernet

Ethernet

T3T3

T1T1

Indiana StateIndiana StateDept HealthDept Health

Marion CoMarion CoHealth DeptHealth Dept

ISDNISDN

T1T1

WHS ClinicsWHS Clinics7 sites7 sites

5 T1 Lines

5 T1 Lines

MidtownMidtownMental HealthMental Health

9 sites9 sites

MidtownMidtownMental HealthMental Health

MeridianMeridian

HospitalsHospitalsClarianClarianMethodistMethodist

ClarianClarianIU/RileyIU/Riley

IUMG ClinicsIUMG Clinics5 sites5 sites

CommunityCommunityEastEast

PeoplesPeoplesHomelessHomeless

9 sites9 sites

CommunityCommunityNorthNorth

WishardWishard

INPCINPC

Fibe

rFi

ber

PittsburghPittsburgh

VPNVPN

One or more clinics/group practicesOne or more clinics/group practices

One or more homeless care sitesOne or more homeless care sites

Public health departmentsPublic health departments

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At the core of the INPC is a At the core of the INPC is a Medical Record SystemMedical Record System

Results retrievalResults retrievalClinical messaging/document deliveryClinical messaging/document deliveryData entryData entryReportingReportingClinical decision supportClinical decision supportData surveying toolsData surveying tools

Specific Implementation ExamplesSpecific Implementation Examples

Florida Marlins Florida Marlins –– A successful A successful implementation.. ;)implementation.. ;)

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Provider AbstractProvider Abstract

Web Inquiry / Web InterfaceWeb Inquiry / Web Interface

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Web Inquiry / Web InterfaceWeb Inquiry / Web Interface

Web Inquiry / Web InterfaceWeb Inquiry / Web Interface

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Examples of Provider RemindersExamples of Provider Reminders

CHIP – 1st

Generation DSS

CHICA CHICA –– 22ndnd Generation DSSGeneration DSS

Child Health Improvement through Child Health Improvement through Computer AutomationComputer AutomationComprehensive Pediatric Preventative Comprehensive Pediatric Preventative Care Decision Support SystemCare Decision Support SystemDesigned around large collection of Designed around large collection of constraints from busy pediatric clinicconstraints from busy pediatric clinic–– Clear tasks that needed improvementClear tasks that needed improvement–– Extremely workflow sensitive personnelExtremely workflow sensitive personnel–– TechnologyTechnology--phobic managementphobic management

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CHICA CHICA -- AttributesAttributes

Interface to practice Interface to practice –– paper and paper and computer basedcomputer basedCollects data in critical times during Collects data in critical times during patient visit, presents data “just in time”patient visit, presents data “just in time”Decision support all based on pediatric Decision support all based on pediatric preventative care guidelinespreventative care guidelinesHas robust access to INPC data, but can Has robust access to INPC data, but can also run autonomouslyalso run autonomously

SampleSampleProvider Provider

Worksheet:Worksheet:

An example of An example of “Just in Time”“Just in Time”

datadata

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CHICA RemindersCHICA Reminders

Support Staff Support Staff BarcodingBarcoding TemplateTemplate

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Implementation PearlsImplementation Pearls

GembaGemba Kaizen ...Kaizen ...

""GembaGemba" is a " is a Japanese word Japanese word meaning "real place", meaning "real place", where the real action where the real action takes place. In takes place. In business, gemba is business, gemba is where valuewhere value--adding adding activities to satisfy the activities to satisfy the customer are carried customer are carried out.out.

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Immunization Registry Immunization Registry GembaGemba

Practitioners need relief! Provide them Practitioners need relief! Provide them with “just in time” data at point of carewith “just in time” data at point of careDisparate workflows necessitate multiple Disparate workflows necessitate multiple interfaces.. let practices chooseinterfaces.. let practices chooseGive support staff easy ways to capture Give support staff easy ways to capture data electronicallydata electronicallyNeeds drive the technology.. “build Needs drive the technology.. “build hammers for the largest nails”hammers for the largest nails”

The Popcorn Man’s PDA

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More More GembaGemba

Lead the user’s needsLead the user’s needsBe careful asking users what they want initially Be careful asking users what they want initially because what they say they want is not what because what they say they want is not what they will use or what they needthey will use or what they needUsers won’t be critical of the options until they Users won’t be critical of the options until they try to use it; likewise they won’t recognize the try to use it; likewise they won’t recognize the problem areas until they try to use itproblem areas until they try to use itDesign for a casual user and against the power Design for a casual user and against the power user.. Simplify clicks, key presses, page turns, user.. Simplify clicks, key presses, page turns, etc.. give them data quickly!etc.. give them data quickly!

Things to AvoidThings to Avoid

AnythingAnything that slows the provider downthat slows the provider downMaking the computer the “bad guy” (e.g. Making the computer the “bad guy” (e.g. coding, lots of extraneous steps)coding, lots of extraneous steps)Being paperless for the sake of being Being paperless for the sake of being paperlesspaperless–– “My clinic will be paperless the same day your “My clinic will be paperless the same day your

bathroom is”bathroom is”

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Short? Term GoalsShort? Term GoalsShare your dataShare your data–– Build ability to Build ability to exportexport data through standards (HL7, data through standards (HL7,

LOINC)LOINC)–– Value of “decentralization” of data: previous examples Value of “decentralization” of data: previous examples

of data useof data use–– More and more researchers and EMR vendors will More and more researchers and EMR vendors will

want to make use of your hard work!want to make use of your hard work!

Evaluate your systemsEvaluate your systems–– Focus on improving quality of care, less on data Focus on improving quality of care, less on data

quality / completeness of dataquality / completeness of data–– Randomized controlled trials that show impact on Randomized controlled trials that show impact on

immunization complianceimmunization compliance

Questions / Comments?Questions / Comments?

Regenstrief welcomes your questions / Regenstrief welcomes your questions / ideas / examples of implementationsideas / examples of implementations

My My EMailEMail: : pbiondich@regenstrief.orgpbiondich@regenstrief.orgMy Phone: 317My Phone: 317--630630--74007400

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