EDI
The Role of Health Care Related IT
Advances In Advancing Public Health
Surveillance
HEALTH
DEPT
CLEARING
HOUSE
John Lumpkin, M.D., M.P.H.,
Senior Vice President and
DirectorDirector-Health Care Group
The Robert Wood Johnson Foundation
PAYER 1
PAYER 2
What does Greater Per Capita Spending
BUY?
not more effective or preference sensitive care
0.99
1.04
1.03
1.00
1.00
0.98
0.97
1.00
1.2
1.18
1.6
1.38
1.66
2.0
1.00
Ratio to Lowest Spending Region
Medicare Reimbursements (Part A and B) in
Relation to the National Average (2000)
0.8
0.4
0.0
Medicare Reimbursements
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
0-15% Below Average
0-15% Above Average
More than 15% Above Average
Asthma: Outpatient Follow-up
After Acute Episodes
• Core concept:
Outpatient followfollow-up
after either ER visit or
admission
• Children 55-17 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
Effective Care
PreferencePreference-Sensitive Care
(Discretionary Surgery)
More than 15% Below Average
Jack Wennberg
Dartmouth
Atlas of Health Care
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
NHII
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.
Framework for
PMRI (Patient Medical Record
Information) Standards
Comparability
Interoperability
ta ty
Da ali
u
Q
Personal
Health
Healthcare Provider
Population
Health
(Preparedness)
Objectives of PMRI Standards
• More easily & accurately exchange
PMRI between systems
• Better understand PMRI across
systems
Inflamed
Ear
?
Overview of PMRI Dimensions
Comparability
Interoperability
ta y
D a a lit
u
Q
Rx
HIPAA
Interoperability Status
Radiology
Laboratories
Patient
HL7 &
Registration/
DICOM
HL7 & ASTM
Hospital
Payers
Admissions
NCPDP &
HL7
Pharmacy
Billing
HL7
ASC
ASC X12N
X12N &
Knowledge
bases
PMRI
PMRI
Physiological
monitors
NCPDP
HL7
HL7
&
Clinical
ASTM
content
Pharmacy
Benefits Mgrs
NCPDP &
ASTM
X12N
& HL7
HL7
Community
IEEE
Medical
IEEE
Pharmacies
Orders
&
Bedside
devices
results
computer
(Adapted from Electronic Health Records: Changing the Vision, Eds. GF Murphy,
MA Hanken, and KA Waters. Philadelphia: W. B. Saunders Company, 1999)
Comparability
Issues
Overview of PMRI Dimensions
Terminology
Vocabulary
Set of highly granular, specialized terms
Comparability
Classification
Organization of related terms
Code
representation
of term
ta y
D a a lit
u
Q
Interoperability
• Comparability requires that the meaning of data is consistent when
shared among different parties
The Health Informatics
Pipeline
Comparability Status
Message Specific Codes
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
Nursing Codes
•
•
•
•
•
•
•
•
HHCC*
NANDA*
NIC*
NMMDS
NOC*
OMAHA*
PCDS*
PNDS
Co
Int
e
Clinically Specific Codes
•
•
•
•
•
•
•
DSM*
Gabrieli
LOINC*
MEDCIN
MedDRA
SNOMED V3*
NHS Clinical Terms*
Drug Codes
•
•
•
*
rop
era
b
mp
a ra
bil
ity
Privacy &
Security
cial &
Finan trative
inis
Adm
ali
ty
•
•
•
•
•
ility
Qu
•Health Language Center
•UMDNS (ECRI)*
•DEEDS
•UPN (HIBCC)/UPC (UCC)
Da
ta
Other Codes
Foundation
HIPAA Standards
Other Standards
Standards Announced March 2003
• HL-7 EMR
• CHI
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
HHS Agencies with NHII
Responsibilities
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
•
•
•
•
•
•
•
AHRQ
ASIRM
ASPE
CDC
CMS
Data Council
FDA
• HRSA
• NCHS
•
•
•
•
NIH
NLM
OCR
OPHS
Issues for the Development of the
NHII
I always knew that Data was a
four letter word,
I just never knew it was spelled
T-U-R-F
Phil Lee, MD
• 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
Interoperability Status
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).
Radiology
DICOM
Patient
Registration/
Pharmacy
Payers
Admissions
HL7 & ASTM
Hospital
NCPDP &
HL7
Billing
HL7
ASC
ASC X12N
X12N &
Knowledge
Physiological
monitors
NCPDP
HL7
HL7
bases
PMRI
PMRI
&
Clinical
ASTM
content
ASTM
Pharmacy
Benefits Mgrs
NCPDP &
X12N
& HL7
HL7
Community
IEEE
Medical
devices
Committee on Assuring the Health of
the Public in the 21st Century - 2002
Laboratories
HL7 &
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
Arthur C. Clarke Laws
• HIPAA
• Cost of Reporting
– Time is money
– Hassle factor
– What’s in it for me?
Third Law:
"Any sufficiently advanced technology is
indistinguishable from magic."
• Reporting as a Quality Measure?
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
An Enterprise View,
Defined Collaboratively,
to build organizational
capability and data
interoperability:
– System Development by Consortium of States
• Web enabled Immunization Registry
• Reuse Model
• ASP Model
A Case Study