The Role of Health Care Related IT
Advances In Advancing Public Health
Surveillance
John Lumpkin, M.D., M.P.H.,
Senior Vice President and
Director-Health Care Group
The Robert Wood Johnson Foundation
EDI
CLEARING
HOUSE
PAYER 1
PAYER 2
HEALTH
DEPT
Medicare Reimbursements (Part A and B) in
Relation to the National Average (2000)
Jack Wennberg
Dartmouth
Atlas of Health Care
More than 15% Above Average (36)
0 - 15% Above Average
(68)
0 - 15% Below Average
(112)
More than 15% Below Average (90)
Not Populated
0.99
1.03
1.04
1.00
1.00
0.97
0.98
1.00
1.2
1.18
1.6
1.38
1.66
2.0
1.00
Ratio to Lowest Spending Region
What does Greater Per Capita Spending
BUY?
not more effective or preference sensitive care
0.8
0.4
0.0
Medicare Reimbursements
Effective Care
More than 15% Below Average
0-15% Below Average
0-15% Above Average
More than 15% Above Average
Jack Wennberg
Dartmouth
Atlas of Health Care
Preference-Sensitive Care
(Discretionary Surgery)
Asthma: Outpatient Follow-up
After Acute Episodes
• Core concept:
Outpatient follow-up
after either ER visit or
admission
• Children 5-17 years old
• Standard based on
national expert panel
guidelines
100
90
80
70
60
White
50
AfricanAmerican
40
30
20
10
0
Follow-up Rate
Quality of Health Care in US??
•
•
•
•
•
•
•
Overall Care
Preventive
Acute
Chronic
History
Counseling or Ed
Immunization
54.9%
54.9%
53.4%
56.1%
43.4%
18.3%
65.7%
Elizabeth McGlynn, et al NEJM June 26, 2003 348:26
The focus must shift from blaming
individuals for past errors to a focus on
preventing future errors by designing safety
into the system
To Err is Human
- Institute of Medicine
Current practice depends upon the
clinical decision-making capacity and
reliability of autonomous individual
practitioners, for classes of problems
that routinely exceeds the bounds of
unaided human cognition
Daniel R. Masys, M.D.
2001 IOM Annual Meeting
“We have wonderful technology,
but some grocery stores have better
technology than our hospitals and
clinics.”
Secretary Tommy Thompson
Chicago Medical School Commencement
June 7, 2002
Vision of the NHII
• The set of technologies, standards,
applications, systems, values, and laws that
support all facets of individual health,
health care, and public health.
• NOT a centralized database.
• Connects distributed health information in
the framework of a secure network with
strict confidentiality protections.
NHII
Personal
Health
Healthcare Provider
Population
Health
(Preparedness)
Framework for
PMRI (Patient Medical Record
Information) Standards
Comparability
Interoperability
Objectives of PMRI Standards
• More easily & accurately exchange
PMRI between systems
• Better understand PMRI across
systems
Inflamed
Ear
?
Rx
Overview of PMRI Dimensions
Comparability
Interoperability
HIPAA
Interoperability Status
Radiology
Laboratories
Patient
HL7 &
DICOM
Registration/
HL7 & ASTM
Hospital
Pharmacy
Payers
Admissions
NCPDP &
HL7
Billing
HL7
ASC
ASC X12N
X12N &
Knowledge
bases
Physiological
monitors
NCPDP
HL7
HL7
PMRI
PMRI
&
Clinical
ASTM
content
ASTM
Pharmacy
Benefits Mgrs
NCPDP &
X12N
& HL7
HL7
Community
IEEE
Medical
devices
IEEE
Bedside
computer
Orders
&
results
(Adapted from Electronic Health Records: Changing the Vision, Eds. GF Murphy,
MA Hanken, and KA Waters. Philadelphia: W. B. Saunders Company, 1999)
Pharmacies
Overview of PMRI Dimensions
Comparability
Interoperability
Comparability
Issues
Terminology
Vocabulary
Set of highly granular, specialized terms
Classification
Organization of related terms
Code
representation
of term
• Comparability requires that the meaning of data is consistent when
shared among different parties
Comparability Status
Message Specific Codes
Other Codes
•Health Language Center
•UMDNS (ECRI)*
•DEEDS
•UPN (HIBCC)/UPC (UCC)
•
•
•
•
•
DICOM
NCPDP
IEEE
HL7*
X12N
Convergence
Diagnoses & Procedure Codes
•
•
•
•
•
•
•
•
Alternative Link*
CDT-2*
CPT-4*
HCPCS*
ICD-9-CM/ICD-9-V3*
ICD-10-CM*
ICD-10- PCS
ICIDH-2
SNOMED RT/
NLM - UMLS
Clinically Specific Codes
•
•
•
•
•
•
•
DSM*
Gabrieli
LOINC*
MEDCIN
MedDRA
SNOMED V3*
NHS Clinical Terms*
Nursing Codes
•
•
•
•
•
•
•
•
HHCC*
NANDA*
NIC*
NMMDS
NOC*
OMAHA*
PCDS*
PNDS
Drug Codes
•
•
•
*
The Health Informatics
Pipeline
Privacy &
Security
Foundation
HIPAA Standards
Other Standards
• HL-7 EMR
• CHI
Standards Announced March 2003
1. LOINC: Laboratory Result Names
2. HL7 Messaging Standards: Includes scheduling,
medical record/image management, patient
administration, observation reporting, financial
management, patient care
3. NCPDP: Includes retail pharmacy transactions
4. IEEE 1073 Messaging Standards: Connectivity
5. DICOM Messaging Standards: Includes Image
Information to Workstations
May 6, 2004
Lab Results Contents
Demographics
Units
Immunizations
Medications
Interventions and Procedures
(A. Lab, B. Non-lab)
Diagnosis/Problem List
Anatomy/Physiology
Nursing
Billing/Financial
Medical Devices and Supplies
Encounters
Disability
Population Health
Text-Based Reports
History and Physical
Multimedia
Genes and Proteins
Chemicals
HHS Agencies with NHII
Responsibilities
•
•
•
•
•
•
•
AHRQ
ASIRM
ASPE
CDC
CMS
Data Council
FDA
• HRSA
• NCHS
•
•
•
•
NIH
NLM
OCR
OPHS
I always knew that Data was a
four letter word,
I just never knew it was spelled
T-U-R-F
Phil Lee, MD
Issues for the Development of the
NHII
• Government Role
–
–
–
–
HIPPA Approach
CHI
800 pound Gorilla
New IT Czar
Architecture Issues
• Options for structure
– Repository based structure
– Directory based structure
•
•
•
•
National Databank
Napster
Systems of Systems
Free floating peer to peer
PUBLIC HEALTH AND
MEDICAL PRACTICE BOTH
USE THE SAME DATA, WE
JUST LOOK AT IT
DIFFERENTLY
- CHRISTINE GEBBIE
Recommendations* to the Secretary of
HHS and DHHS agencies
Recommendation 1. Appoint a national commission to
develop a framework for state public health law reform.
Recommendation 5. Initiate a broad-based national
dialogue, led by a national commission convened by the
Secretary of HHS, to explore perspectives on workforce
credentialing, and to outline next steps based on
decisions reached.
Recommendation 7. Facilitate the development and
implementation of the National Health Information
Infrastructure (NHII).
Committee on Assuring the Health of
the Public in the 21st Century - 2002
Interoperability Status
Radiology
Laboratories
Patient
HL7 &
DICOM
Registration/
HL7 & ASTM
Hospital
Pharmacy
Payers
Admissions
NCPDP &
HL7
Billing
HL7
ASC
ASC X12N
X12N &
Knowledge
bases
Physiological
monitors
NCPDP
HL7
HL7
PMRI
PMRI
&
Clinical
ASTM
content
ASTM
Pharmacy
Benefits Mgrs
NCPDP &
X12N
& HL7
HL7
Community
IEEE
Medical
devices
IEEE
Bedside
computer
Orders
&
results
(Adapted from Electronic Health Records: Changing the Vision, Eds. GF Murphy,
MA Hanken, and KA Waters. Philadelphia: W. B. Saunders Company, 1999)
Pharmacies
Issues for Health Care
• HIPAA
• Cost of Reporting
– Time is money
– Hassle factor
– What’s in it for me?
• Reporting as a Quality Measure?
Arthur C. Clarke Laws
Third Law:
"Any sufficiently advanced technology is
indistinguishable from magic."
First Wave of Public Health
System Development
• State based Systems
– Metabolic Disease
• Federal Systems for State Usage
– HIV/AIDS Registry 1987
• In the beginning we saw that it was good...
Second Wave of Public Health
Information System Development
• State Developed Systems
– Integrated
• Cornerstone – 1993- Illinois
–
–
–
–
WIC
Immunization
Case Management
Well Child
– Stand alone
• Immunization registries
Third Wave of Public Health Information
System Development
• Federal Centric
– State developed prototype
– Installed in many states
• State Centric
– System Development by Consortium of States
• Web enabled Immunization Registry
• Reuse Model
• ASP Model
An Enterprise View,
Defined Collaboratively,
to build organizational
capability and data
interoperability:
A Case Study