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Popula'on Health, Public Health, & Meaningful Use
James W. Buehler, MD Health Commissioner
Philadelphia Department of Public Health
Delaware Valley Chapter HIMSS January 29, 2015
1
Overview: What are the connec'ons across Public Health, Popula'on Health, &
Healthcare?
• Phila. Dept. of Public Health: Who are we? • How is our shared landscape evolving? • What are the impacts of
– Meaningful Use – Affordable Care Act
• Where are we: public health repor'ng & MU? • What’s on the horizon?
2
PDPH Vision & Mission
• Our vision is of a city in which every resident is able to: – Live a long, healthy, and produc've life; – Be free of preventable disease and disability; and – Live, work, learn, shop, and play in environments that promote
health.
• Mission: To protect and promote the health of all Philadelphians and to provide a safety net for the most vulnerable.
3
• Environmental Health – Restaurant inspec'ons, vector control,
lead poisoning preven'on
• Air Management Services – Air quality monitoring, regula'on,
commercial noise control
• Disease Control – STD, TB, flu, outbreak response,
disease monitoring, emergency preparedness
• AIDS AcBviBes CoordinaBng Office – Preven'on, screening, treatment
• Chronic Disease PrevenBon/Get Healthy Philly
– Tobacco control, obesity preven'on
• Maternal, child, & family health − Home visi'ng, breas[eeding
• Medical Examiner’s Office
− Autopsies, fatality review programs, bereavement support
• Public Health Lab − Clinical, public health, emergency
preparedness
• Ambulatory Health − 8 primary care health centers, EHR
rollout
Public Health is Popula'on Health: PDPH opera'onal divisions
4
Health Promo'on & Protec'on: Programs & Partnerships
6
Opening of New Neighborhood Farmers Market Chris'an Street YMCA, September 2014
Image: Green Mountain Energy
HIT, HIE, & QI: Long-‐term trends accelerated by Meaningful Use
• Beher informa'on for pa'ent care • Beher informa'on about popula'on health
– People enrolled in an insurance program – Pa'ents under care of a provider – People in a poli'cal jurisdic'on – We need to know:
• What is the health of our “popula'on?” • How well are we doing our job?
– Requirements of interest to public health: • ReporBng to health departments: PopulaBon health monitoring • Promote use of preven've services: prompts and QI measures • Decision support
8
Public Health Repor'ng in Meaningful Use
• Disease surveillance – Monitor trends – Characterize at-‐risk popula'ons – Iden'fy urgent situa'ons – Inform programs – Meaningful Use:
• Lab results for reportable condi'ons • “Syndromic” surveillance • Immuniza'on registry, aka Immuniza'on Informa'on System (IIS)
• Cancer registry (new, in Stage 2)
10
Disease Repor'ng Mandated by State Law www.health.state.pa.us
• Physicians, clinics, hospitals, laboratories • Lab-‐ini'ated repor'ng for infec'ous diseases
– Promotes 'meliness & completeness – Focus on large commercial labs (predates MU) – S'll need remainder of clinical info
• Meaningful Use – Hospitals: Lab results for reportable condi'ons
• Onboarding & ahesta'on: Via State Health Dept. • No Phila. Hospitals yet onboarded
– Future: fully automated case repor'ng (clinical & lab info) • ONC did not select for inclusion in Stage 3 • Focus of ac've development
11
Electronic Laboratory Repor'ng Data Managed More Quickly
0%
20%
40%
60%
80%
100%
% Cases thru ELR
2010 2011 2012 2013
0
3
6
9
12
Mean # Days 'l Ac'on
2010 2011 2012 2013
Example: Summer 2013 Salmonella outbreak associated with catered lunches detected in 2-‐3 days aqer onset of illness 12
All reportable diseases Salmonella cases
Automated Repor'ng: High Volume Diseases Can Be Addressed
11,140 12,820
14,539
19,785
0
4,000
8,000
12,000
16,000
20,000
24,000
2010 2011 2012 2013
PosiBve HCV Test Reports
Impact: Faster recogni'on, detec'on, & inves'ga'on of acute infec'ons 13
Philadelphia Immuniza'on Registry: KIDS Plus
• Philadelphia and State Registries • Ahesta'on via both registries
• Providers in Phila. required to report to Phila. KIDS Plus (Child & Adult)
• State downloads reports to Phila. KIDS Plus
• Phila. to state uploads (under development)
• KIDS Plus Data collec'on: • HL7 Interface – 2.3.1 and 2.5.1
• Billing or EMR delimited files
• Direct entry
• Paper logs
• Methods of transport: • Batch messaging to sFTP
• SOAP web services
KIDS Plus: Improved Timeliness
2012 2014
Overall 33 23
HL7 “Real Time” N/A 0
HL7 Daily Batch N/A 2
EMR Flat File (~monthly) 25 35
Billing (~monthly) 39 35
Manual (in house) 78 14
Median Number of Days between Vaccina'on and Entry into KIDS Plus
• Populated using weekly feed from state e-‐birth cer'ficates • >1,000 Ac've Users (providers, school nurses, prison health, shelters • ~45 providers (of 165) using HL7 repor'ng • Backlog of adult vaccina'ons reported via insurers’ billing records • State forwards into for Phila. residents
15
KIDS Plus IIS Repor'ng Vaccina'on Counts (Cumula've Jan-‐Dec)
by Repor'ng Method 2014 2012
1.93 million vaccina'ons 54% received through HL7
1.21 million vaccina'ons 3% received through HL7
16
Syndromic Surveillance
• Rapid snapshot of health status for broad syndrome groups • Limited data collec'on: demographics, chief complaint or
discharge diagnosis • Hospital ED: most common source • Philadelphia: “Home grown” system started in 2002
– Transi'oning to State system • Operated by: Health Monitoring Systems, Inc. (HMS)
– Current: 16 via HMS; 3 via legacy system • Meaningful Use
– Onboarding & ahesta'on via State/HMS – Emphasis on hospital EDs – No funding to support onboarding for outpa'ent providers
17
Example: Use of ED-‐based Syndromic Surveillance for “Influenza-‐Like Illness” in Combina'on with Other Data hhps://hip.phila.gov/xv/
18
Repor'ng to Cancer Registry
• Menu Op'on in Stage 2 • Managed by state cancer registry
19 hhp://www.portal.state.pa.us/portal/server.pt/community/pa_cancer_registry/14280
CMS Quality of Care Measures Align with Public Health Objec'ves
Adults • Controlling High Blood
Pressure • Tobacco Use: Screening
and Cessa'on Interven'on
• Screening for Clinical Depression and Follow-‐Up Plan
• Body Mass Index (BMI) Screening and Follow-‐Up
Children • Weight Assessment and
Counseling for Nutri'on and Physical Ac'vity
• Chlamydia Screening, 16+ • Childhood Immuniza'on
Status • Appropriate Treatment
for URI • Children who have dental
decay or cavi'es
20 hhp://www.cms.gov/Regula'ons-‐and-‐Guidance/Legisla'on/EHRIncen'vePrograms/2014_ClinicalQualityMeasures.html
American Reinvestment & Recovery Act, 2009 Health InformaBon Technology for Economic and Clinical
Health Act (HITECH) $33 Billion
Source: hhp://www.ahima.org/advocacy/arrahitech.aspx
CMS
NTIA
DoA
ONC
HRSA
AHRQ
SSA
I H S
VA
Government public health represents 3% of U.S. health spending NaBonal Health Expenditures, 2014, $3.1 Trillion
Government Public Health
All other
Source: Centers for Medicare and Medicaid Services. Na'onal Health Expenditure Projec'ons 2012-‐2022. hhp://www.cms.gov/Research-‐Sta's'cs-‐Data-‐and-‐Systems/Sta's'cs-‐Trends-‐and-‐Reports/Na'onalHealthExpendData/Na'onalHealthAccountsProjected.html
Will Meaningful Use be meaningful for public health?
• Required repor'ng easier for providers • Easier for public health staff-‐-‐allows shiq of ahen'on from collec'ng to using informa'on
• Fulfills a clear PH need for informa'on • Informa'on provided back to providers and public
• Value and impact of informa'on is apparent • Strengthens healthcare-‐public health collabora'on
23
PDPH Implemen'ng EHR in network of 8 primary care clinics
• Stages – Prac'ce management system
– Medical record
– Interfaces & connec'ons, including regional HIE – Analysis capabili'es
• QI & performance measures
• Research (data-‐use policies) • Issues:
– Planning, training, accommoda'ons, legacy data, upgrades
– Cultural alignments • Informa'cs • IT • Clinical • Public Health
– Integra'on with STD & TB clinics
• Opportunity to model new healthcare-‐public health collabora'on 25
Affordable Care Act: Not just health insurance
• Alignment of clinical and public health priori'es
• Importance of chronic diseases
• Emphasis on con'nuity of care – Among healthcare providers
– Between healthcare & the community
• Example: Role of Community Health Workers
• Community health needs assessment (CNHA), response implementa'on plans – Not-‐for-‐profit hospitals, repor'ng to IRS
– CNHA: • Requires engagement of state/local PH agency (new) • Allows for collabora'on and sharing of community-‐wide assessments
– Response/implementa'on • Most emphasize un-‐reimbursed care or training • Small percentage of investments for outside-‐hospital community benefit ac'vi'es
• New opportuni'es for Healthcare & PH collabora'on – Example: Phila. Community Health Improvement Plan – www.phila.gov/health/commissioner/pha.html
26
Mul'ple Chronic Diseases • Aging of baby boomers • Impact on healthcare use and costs • Leading contributor to premature death & preventable morbidity • Poverty strong determinant of poor outcomes • Outcomes affected by:
– Healthcare – Home & community situa'ons
1980 & 2010 27
Improve health security at home and around the world
Better prevent the leading causes of illness, injury, disability, and death
Strengthen public health/ health care collaboration
CDC strategic directions
Health Care
Public Health
CDC, 2014, www.cdc.gov
Example: New CDC-‐funded Project to Improve Healthcare & Public Health Collabora'on
• Learning collabora'on: PDPH + 40 prac'ces – FQHCs: Health Federa'on of Philadelphia – Hospital-‐based: Health Care Improvement Founda'on
• Set common goals (HEDIS-‐based) – Disease iden'fica'on, medica'on adherence, disease control
• Use EHRs to monitor care, based on MU requirements • Pa'ent educa'onal resources • Explore models for engaging community health workers • Primary preven'on
– Diabetes Preven'on Program to Medicaid beneficiaries at discount (~$25) – Partnership with YMCA – CDC-‐designed 16-‐week program for people at high risk for diabetes. – Educa'on on diet and physical ac'vity – Reduces the incidence of diabetes
29
Conclusions
• Kinship between healthcare and public health views of popula'on health – Accelerated by Meaningful Use and ACA
• Progress and challenges in achieving aims of Meaningful Use
• Increasing importance of healthcare & public health collabora'on
30
For addi'onal informa'on hhp://www.dhs.state.pa.us/provider/healthcaremedicalassistance/medicalassistancehealthinforma'ontechnologyini'a've/meaningfuluse/index.htm
hhp://www.dhs.state.pa.us/cs/groups/webcontent/documents/document/p_039230.pdf Philadelphia
Immuniza'ons Amira Elhagmusa, MPH Tel: 215.685.6494 Amira.Elhagmusa@phila.gov
Syndromic José Lojo, MPH Tel: 215.685.6849 Jose.Lojo@phila.gov
Claire Newbern, PhD MPH Tel: 215.685.6495 Claire.Newbern@phila.gov
Pennsylvania
Immuniza'ons Frank Caniglia ccaniglia@pa.gov
Syndromic Kirsten Waller kwaller@pa.gov
Hospital Lab Results Mark Dihman mdihman@pa.gov
HIMS – syndromic (outpa'ent) Ben Luffey ben.luffey@hmsinc.com
Cancer Registry Wendy Aldinger wealdinger@pa.gov
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