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Are EHR’s enough for population health?
Lisa Dolan-BrantonIndian Health Service
AHRQ Annual Conference Sept 15, 2007
Objectives• Indian Health Service• HIT Strategic Priorities• Population Health
• What matters
Who are We?• A comprehensive health service delivery A comprehensive health service delivery
system for approximately 1.9 million of 3.3 system for approximately 1.9 million of 3.3 million American Indians and Alaska Natives million American Indians and Alaska Natives from 562 federally recognized tribes in 35 from 562 federally recognized tribes in 35 states states
• FY 2009 spend authority is over 4 billion. FY 2009 spend authority is over 4 billion.
• Indian Health Service total staff consists of Indian Health Service total staff consists of about 15,600 employees, which includes about 15,600 employees, which includes approximately 2,500 nurses, 1600 CHRs, 900 approximately 2,500 nurses, 1600 CHRs, 900 physicians, 500 pharmacists, and 300 dentistsphysicians, 500 pharmacists, and 300 dentists
The IHS Mission, in partnership The IHS Mission, in partnership with American Indian and Alaska with American Indian and Alaska Native people, is to raise their Native people, is to raise their physical, mental, social, and physical, mental, social, and
spiritual health to the highest spiritual health to the highest level.level.
AI/AN Rate AI/AN Rate 2002- 2004 2002- 2004 ALL CAUSESALL CAUSES 1027.2 1027.2 832.7 832.7 1.21.2
TuberculosisTuberculosis 1.71.7 0.2 0.2 8.58.5
DiabetesDiabetes 74.274.2 25.325.3 2.92.9
Unintentional Injuries Unintentional Injuries 94.8 94.8 37.3 37.3 2.5 2.5
SuicideSuicide 17.917.9 10.810.8 1.71.7
Cervical cancerCervical cancer 4.74.7 2.5 2.5 1.91.9
Infant deaths Infant deaths 1/1/ 11.711.7 6.9 6.9 1.71.7
Pneumonia/InfluenzaPneumonia/Influenza 32.332.3 22.022.0 1.51.5
1/ Infant deaths per 1,000 live births
US All Races US All Races Rate Rate 2003 2003
Ratio:Ratio:AI/AN toAI/AN to
US All RacesUS All Races
MORTALITY RATE MORTALITY RATE DISPARITIESDISPARITIES
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A Broader Picture of Health
Personal Health Family Health Community Health Public Health Population Health Transparency of Data
Patient and community sharing of informationCommitment to Health Equity
IHS Strategic Priorities
• Build and sustain healthy communities• Provide accessible, quality healthcare• Foster collaboration and innovation across
the Indian Health network•• IHS Strategic Priorities are supported by • technology initiatives, not driven by them.
Care Model for the Indian Health System
Improved health and wellness for American
Indian and Alaska Native individuals, families, and
communities
Delivery SystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Community Health Care Organization
Activated Family and Community
Informed
Activated
Patient
Prepared
Proactive Care Team
Prepared,Proactive
Community PartnersEFFECTIVE RELATIONSHIPS
Efficient Safe
EffectiveEquitable
TimelyPatient-Centered
Care Model for the Indian Health System
Improved health and wellness for American
Indian and Alaska Native individuals, families, and
communities
Delivery SystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Community Health Care Organization
Activated Family and Community
Informed
Activated
Patient
Prepared
Proactive Care Team
Prepared,Proactive
Community PartnersEFFECTIVE RELATIONSHIPS
Efficient Safe
EffectiveEquitable
TimelyPatient-Centered
Use data at the point of careFacilitate individual patient care planningIdentify relevant subpopulations for proactive careProvide timely automated reminders for providers
and patientsShare information with patients Allow staff to coordinate care Monitor performance of practice
team and care systemInvolve the family, community and populations
http://www.ihs.gov/CIO/RPMS
Resource & Patient Management System (RPMS)
• Developed in the 1980s• Over 60 software applications• Used at over 400 sites• ‘ Every little thing she does is magic’
PCCPatient
Database
Case Management Data EntryReferred Care
Diabetes Management
Elder Care
Patient Registration
Laboratory
Emergency Room
Public Health Nursing
Pharmacy Appointment System Occupational Med
CHR
Radiology
Immunizations
Women’s Health
Dental
Behavioral Health
PCC ( Health data repository)
Meaningful Use and Pop Health• Quality measures for populations
• Populated by patients• Ability to report at POC as well as export• Tracking of quality improvement
• Ability to share interoperable data with others• Immunization data sharing• Lab data sharing
• Early sentinel awareness of public health issues• Use of iCARE
• Suicidal Behavior Surveillance• CDC Nationally Notifiable Diseases• H1N1
16
iCare Population Management
iCare is Used to….(in descending order)• Track performance on GPRA and other national measures • Manage and track group of patients with a chronic disease • Pre-visit or clinic planning to care for patients with
appointments on a particular day • Manage and track patients assigned to specific provider• Track patients who need or have received a specific service• Track provision of age and gender-specific preventive care
services• Share panel among care team• Target needs within a geographic area or community
Facilities who are part of the IHS Learning Collaborative more frequently reported using iCare for all of these listed functions with the exception of targeting geographic areas
H1N1• Decision made on a Friday to code query and export
file • Codes reviewed/ tested/ updated on Q man queries
at large live database• Query logic developed over 4 hours- based on
previous quality work• Export logic based on previous work done on
bidirectional state based immunization data sharing• Coding done in 8 hours• Testing in 2 days on 3 mirror live data bases• First exports received within 5 working days of initial
decision• Over 400 sites with passive nightly exports to Indian
Health Service epi center• Logic shared with private vendors
Lessons Learned-orwhy could we do this?• Relied on ICD codes, not text based POV• Our “EA” had been, by luck, designed to facilitate
boolian logic queries (we knew had to have ‘function’ between the domains)
• Applications developed in the last 10 years had relied on electronic queries of different data domains
• Export files had been previously developed• Lessons learned had influenced data model
decisions as well as understanding of most efficient ways to write M queries in our system
• Logic/ data model that supported population health• EHR architecture MUST support pop health from the
beginning
what matters?ForesightTrustCommitment Adequate ResourcesAppropriate architecture for the Electronic
Health Record to support population health
Health Equity- keeping an eye on the ball
