HIT AND HSR FOR ACTIONABLE KNOWLEDGE:
HEALTH SYSTEM SUMMARY
PARTNER: Palo Alto Medical Foundation (PAMF) of Sutter Health and the
PAMF Research Institute (PAMFRI)
Organization and IT Infrastructure
Organizational Description and History
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Founded in 1930 as Palo Alto Medical Clinic, PAMF is a non-profit, multispecialty group medical practice of over 900 physicians and 600,000 patients in 4
Northern CA counties.
Since 1993, PAMF has been a part of Sutter Health, a network of 24 affiliated
hospitals and 3,500 physicians in northern CA.
In 2008, PAMF merged its three geographically-based medical groups into a
single organization.
Electronic Health Record (EHR) History
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PAMF first adopted Epic’s EHR in 2000.
Since 2008, it is a single EHR system that can be accessed from any PAMF
facility with a patient portal (PAMFOnline).
Sutter hosts EPIC, billing application (IDX), laboratory application (MISYS), IT
personnel, and data warehouse from all PAMF and other Sutter sources at its
Sacramento facility.
PAMF is in the process of switching from IDX to Epic module for billing and
registration.
Research Influence in EHR Design
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Since the merging of PAMF’s three medical groups into a single organization in
2008, PAMFRI personnel have been involved in the revision of data sourcing for
research services as described in following sections.
Recently, researchers are arguing to have new PAMF-developed race and
ethnicity detail collected across the Sutter system for clinical and research
purposes.
Data Management
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PAMF maintains a data warehouse for operational purposes behind the PAMF
clinical firewall.
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Data extracted from data warehouse on a daily basis (with 1-day lag) to populate a
separate PAMFRI Data Repository behind PAMFRI-specific firewall.
Non-Epic data are merged retrospectively into the Repository because of a lack of
seamless interoperability.
Some additional, department-specific data also reside outside of Epic and are not
merged into the Repository. They can be made available for research purposes on
an ad hoc basis.
A de-identified data set is extracted from PAMFRI Data Repository and expanded
on a project-by-project basis behind the PAMF firewall. (See discussion below re
IRB and Privacy Officer reviews.)
Data Available for Research
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Billing
Scheduling
Care management
Vital signs
Laboratory results
Medication orders
Pathology
Oncology
IT Support for Research
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The PAMFRI IT staff and its contracted Tech Team to Go (TT2GO) create
project data files from Data Repository and provide other IT support to
researchers. This staff includes a Director of Information Management and three
Information Management Analysts.
In 2010, concerns for patient privacy and data security resulted in the PAMFRI
Director of Information being made accountable to the PAMF Chief Information
Officer responsible for the security of patient care and business systems rather
than the PAMFRI director to whom he used to report. He and his staff continue to
provide exclusive support to PAMFRI researchers as before.
Separate Sutter/PAMF IT staff members extract data from a corporate Data
Warehouse for inclusion in PAMFRI Data Repository.
In recent years, there has been a gradual centralization of PAMF support services
to Sutter.
Research Environment
How is Research Organized?
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PAMFRI was founded in 1950 with a focus on bench and clinical science.
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The availability of data about patients in the health system and the emergence of
questions about the costs and quality of health care brought health services and
health policy research projects to PAMFRI.
This began in 1963 when Anne Scitovsky joined the then-named Palo Alto
Research Foundation to undertake first-ever research on the cost of illness and
financial impacts of medical technology within what became the Department of
Health Policy. Her work was based on extracting data from paper charts.
PAMFRI currently comprises 5 departments: (1) cardiovascular physiology &
biophysics, (2) clinical research, (3) health policy research, (4) health services
research and (5) research and strategic analytics. The first is the remaining basic
science work and will be closing upon the retirement of its faculty.
The department of Health Services Research, created in 1997, largely conducts
behavioral health research, typically with randomized, but not double-blinded
methods, focused on understanding and reshaping high-risk behavior among
individuals, and on motivating providers to try new approaches to patient care.
The department of Health Policy Research largely conducts observational studies
using methods ranging from ethnography to econometrics with the goals of
improving quality and reducing costs.
The department of Clinical Research undertakes various clinical studies, often
using the EHR to find potentially eligible patients.
Research and Strategic Analytics brings together the analytic expertise of
researchers in various departments to address issues that may be of interest to
PAMF operations and the medical group.
Health services researcher Hal Luft joined PAMFRI as its director in 2008. The
PAMFRI director reports to the PAMF CEO and an oversight committee of the
PAMF Board.
PAMFRI staff comprises 62 people (n.b. not FTEs). Core research personnel
comprise 16 people in the HSR department and 17 people in the Health Policy
department.
PAMFRI, including its Health Policy and Health Services Research departments,
is located on one campus in Palo Alto, CA, although research studies and other
analysis can include patients from all PAMF facilities in northern CA.
Research Culture
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PAMFRI is a formal affiliate of both Stanford and UCSF in their NIH-based
Clinical and Translational Science Award programs.
Some PAMFRI researchers collaborate with investigators at other institutions on a
project-by-project basis.
In addition, some PAMFRI researchers have traditionally maintained faculty
appointments at Stanford or other local universities.
Both internally and externally-funded HSR/Health Policy research is expected to
result in peer-reviewed publications.
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Research Funding
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Most PAMFRI research is funded externally by federal and foundation grants.
Internal funding to respond to PAMF requests is relatively new and growing.
Internally-funded research/analytic opportunities to assist PAMF are identified by
PAMFRI Director through active involvement in PAMF committees.
Internally-funded projects are seen as potential seeds for additional, externallyfunded research.
Data Stewardship
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The PAMF IRB reviews all PAMFRI studies irrespective of data source (i.e.
PAMFRI does not maintain an IRB separate from that used by the rest of PAMF).
Projects requiring access to identifiable patient-level data (including preliminary
work and QI work supported by PAMFRI staff not needing IRB review) must be
approved by the PAMF Privacy Officer. Projects that can be done with just the
de-identified files maintained by PAMFRI do not require Privacy Officer review.
PAMFRI requires all use of patient level data to be tracked with a Data Access
Plan. This includes both identifiable and de-identified data sets.
Identifiable data is not downloaded to PCs or laptops, but de-identifiable data may
be, if necessary. All laptops are encrypted.
Organization of Quality-Related Functions
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The PAMF Quality and Planning department converts EHR data into actionable,
clinical information for operational purposes. (e.g. percent of diabetics meeting
hemoglobin A1C goals).
PAMF Quality and Planning quality metrics are included PAMFRI Data
Repository and are available for research.
Other PAMF-wide quality-related analytic capabilities include research related to
primary care redesign, compliance, outcomes improvement, and PAMF’s Quality
Improvement Steering Committee (QISC).
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