Lessons Learned: Indiana J. Marc Overhage, MD, PhD, FACP, FACMI President and CEO, Senior Investigator, Regenstrief Institute, Inc. Professor, Indiana University School of Medicine
Indiana Network for Patient Care The only existing Regional Health Information Infrastructure Up and running for over 10 years Entirely standards based Focused on clinical and public health issues Started with a emergency department care Extended by adding uses incrementally Hundreds of health services and clinical research projects
Founded in 1969 by Sam Regenstrief Affiliated with IU School of Medicine ~$12M annual budget largely from federal grants Pioneers in medical informatics Standards: HL7, LOINC EMRs: RMRS, INPC Founded in 1999 by 50 community physicians Central Indiana Coalition to Reinvent Health Care Early seed funding from Health & Hospital Corporation of Marion County Initiated community clinical messaging concept Founded in 2002 by the Central Indiana Corporate Partnership Economic development organization promoting academic/industry collaboration in life sciences
IHIE Vision To use information technology and shared clinical information to: Improve the quality, safety, and efficiency of health and health care in the State of Indiana Create unparalleled research capabilities for health researchers Exhibit a successful model of health information exchange for the rest of the country Facilitate the development and adoption of new health-related technologies, which is likely to result in new job opportunities in the Central Indiana economy.
Initial Organizations and Board Biocrossroads - CEO City of Indianapolis - Mayor Clarian Health Partners - CEO Community Health Network - CEO Health and Hospital Corporation CEO * Indiana State Department of Health - State Health Commissioner * Indiana State Medical Association - President Indiana University School of Medicine - Dean The Indianapolis Medical Society - President Marion County Health Department - Chief Medical Officer * Regenstrief Institute - CEO St. Francis Hospital and Health - CEO St. Vincent Healthcare - CEO At large (2) * * * Former ICC Board Members
Specify statistical breakdowns
Two Words Standards Architecture
Clinical Data Standards Current HL7 messages for most DICOM messages for images LOINC for laboratory results content CPT-4 for procedures content ICD-9 for diagnoses content NDC RxNorm for medication content Anticipated Patient: John Doe MRN: Patient: 123-0 John Doe Diagnosis: MRN: 123-0 410.0 WBC: Diagnosis: 14,000/cm 410.0 WBC: 14,000/cm 3 3 SNOMED/CUIs for microbiology content
Messaging Standards What information is requested Where is the information in the message Example: letter message Sender Date Addressee Body Janet Marchibroda ehealth initiative 1500 K Street NW Washington, DC 00000 March 7, 2005 Dr. David Brailer 200 Independence Ave NW Washington, DC 00000 Dear David, Thank you meeting with us last week, we are pleased.
Don t make it complicated! HL7 2.x works just fine Problems all come from flagrant disregard of the HL7 specs e.g.: Coded data sent without codes or coding system (just text) Units appear in value field instead of units field Technical improvements (including new standards) can t fix this
Indiana Network for Patient Care Electronic health information exchange which connects a wide range of stakeholders (real world) Hospitals (100%) Nursing home School based clinics Community Health Centers Homeless heath networks (100%) Public health systems (state and local) Radiology centers (1 of 3) Regional laboratories (4 of 6) National laboratories (1 of 2) Pharmacy Benefit Managers (PBMs) / Pharmacies Practicing physician (60%)
Coding Results HL7 message issues Results often hidden (text with it) Combined results (no shigella, salmonella or E. coli, GC isolated but no Chlamydia, if you suspect your patient has M. tuberculae) Abnormal flag Corrections/changes
Content Standards Who patient Who provider When What both order/report/observation sides use the same codes for When these encounter life is identifier good! (billing number) Where location/addresses
HPI: Patient is a 38 year old white female complaining of a 3 day history of nausea, vomiting and diarrhea. PMH: questionable appendectomy FH: mother died at age 82 of lung Data formats Continuous (big, complete, easy, dumb) Discrete -- text (small, partial, easy, +- smart) Discrete -- codes (small, partial, hard, smart)
Level 1 2 3 4 HIE Taxonomy Description Non-electronic data Machinetransportable data Machine-organizable data Machine-interpretable data Mail, No PC/information phone technology PC-based and manual fax, secure e-mail Fax/Email of scanned documents Secure e-mail of free text or Structured messages, incompatible/proprietary file non-standard content/data formats, HL-7 message Automated entry of LOINC results Structured from an messages, external lab into standardized a primary care content/data provider s electronic health record Examples
Achieving full value requires Percent 100 90 80 70 60 50 40 30 20 10 0 structured data 19% Capture electronically 5% Connect & interface 76% Standardize and store data Source: Center for Information Technology Leadership, IHIE calculations
Starting Point Structuring Data Costs Optimum Value Usefulness of Data Impact on Usability Images Electronic Partially free text structured Rigidly structured
Where in the flow to standardize? Standardizes Converts Message to standard Structure codes Laboratory On Information Raw HL7 the HL7 System Reader Std way HL7 HL7 Pro- DB in! write Standardized cessor Database Institution Specific Mapping Table
Architecture Options Switch Monolithic database Federated consistent databases Federated inconsistent (including peer to peer) Patient carried
Patients Providers Hospitals Diagnostic Services Payors Public Health Providers Provider asks if there are records for his/her patient Individual Care Providers Public Health Provider asks for and receives records Index sends location of any records De-Identified Data FIND Patient Index GET Message Transfer SEND Reporting Router Source: 2004 The Markle Foundation Graphic adapted from Tom Benthin original. Records are sent to Provider Source may push data for reporting Source sends index information REPOR LOCATOR TING Data Sources DATA Patients Providers Hospitals Diagnostic Services Payors Public Health Providers
Records are sent to Provider Gateway Repository Source sends index information Source may push data for reporting Standardized Records are sent Data Sources LOCATOR REPORTING Standardization and Interface Engine DATA Raw Records are sent Points in the process where the institutional firewall could sit. Interface Engine Source Systems
Centrally Managed Individual Care Providers Public Health De-Identified Data FIND Patient Index GET Message Transfer Shared Interoperability Components Standardized Repository Standardized Repository Standardized Repository Standardized Repository Standardized Repository Standardization Institutional Interoperability 2005 Regenstrief Components Institute, Inc. Source Systems Source Systems Source Systems Source Systems Source Systems Data Source
Storage Strategy Central management Separate medical record vault per institution Each vault in separate physical files Standardized data structure all use same software and observation codes Combine on the fly when needed Patient linking