implementation (an lhii supporting care, public health and research in indianapolis ) clem mcdonald,...

Implementation Implementation (An LHII (An LHII supporting care, public health and supporting care, public health and

research in Indianapolisresearch in Indianapolis))Clem McDonald, M.D., FACPClem McDonald, M.D., FACP

Marc Overhage, M.D., Ph.D., FACPMarc Overhage, M.D., Ph.D., FACPMike Barnes, M.D.Mike Barnes, M.D.Paul Dexter, M.D.Paul Dexter, M.D.

NHII 2004 Cornerstones for Electronic HealthcareNHII 2004 Cornerstones for Electronic HealthcareWashington, DCWashington, DC

July 22, 2004July 22, 2004

Regenstrief Institute

1050 Wishard Blvd, 5th floor

Indianapolis, IN 46202

2004 © Regenstrief Institute, Inc.

It is more important to build It is more important to build the highway ….the highway ….


Highway


… … than the Hotel or Fast Food than the Hotel or Fast Food Place Place


The Local Health Information The Local Health Information Infrastructure is the highwayInfrastructure is the highway It connects the health care It connects the health care

playersplayers It delivers clinical data in It delivers clinical data in

standardized form to the users standardized form to the users It provides the guard rails and It provides the guard rails and

protections for data riding on the protections for data riding on the highwayhighway


The office EMR is the hotel The office EMR is the hotel along the roadalong the road It accepts the clinical data from It accepts the clinical data from

the LHII feedsthe LHII feeds Provides special local services Provides special local services But hotel is not the only choice – A But hotel is not the only choice – A

camp ground (ASP web EMR) might camp ground (ASP web EMR) might sufficesuffice


The highway always comes The highway always comes firstfirst You don’t build hotels and fast You don’t build hotels and fast

food restaurants and expect that a food restaurants and expect that a highway will show up highway will show up

It is the other way aroundIt is the other way around Same with the LHII and medical Same with the LHII and medical

record systems. Build the LHII firstrecord systems. Build the LHII first


Highway is key because so Highway is key because so much electronic clinical data much electronic clinical data lives beyond the officelives beyond the office Commercial/referral laboratory resultsCommercial/referral laboratory results Out side consultants notes Out side consultants notes Hospital produced data (all kinds) Hospital produced data (all kinds)

1.1. Operative notesOperative notes2.2. Pathology reportsPathology reports3.3. Discharge summariesDischarge summaries4.4. Cardiology studiesCardiology studies5.5. Radiology reportsRadiology reports6.6. Tumor registryTumor registry7.7. More…More…

Prescription records (in pharmacy benefit Prescription records (in pharmacy benefit management systems)management systems)

More.. More..


INDIANAPOLIS NETWORK INDIANAPOLIS NETWORK FOR PRIMARY CARE (INPC)FOR PRIMARY CARE (INPC) Up and running for more than 7 yearsUp and running for more than 7 years Began with one project – provide data Began with one project – provide data

from all hospitals for Emergency care from all hospitals for Emergency care We Extended by adding public health, We Extended by adding public health,

other practice/MD access mechanisms, other practice/MD access mechanisms, and research--- a step at a timeand research--- a step at a time

Focus on Clinical, public health and Focus on Clinical, public health and research uses issues –- so farresearch uses issues –- so far


Indianapolis Network for Indianapolis Network for Patient Care (INPC) – a real Patient Care (INPC) – a real living LHIIliving LHII1)1) A central (community) clinical A central (community) clinical

repository repository

2)2) A secure network for delivering clinical A secure network for delivering clinical data messages to repositorydata messages to repository

3)3) Tools and processes for standardizing Tools and processes for standardizing the data and using it for different the data and using it for different purposespurposes

4)4) Formal agreements among all Formal agreements among all participants spelling out processes and participants spelling out processes and allowable uses and HIPAA complianceallowable uses and HIPAA compliance


Advantage of centralized Advantage of centralized repository for LHII repository for LHII

Standardizing happens centrally with Standardizing happens centrally with concentrated expertiseconcentrated expertise

Apply one effort to standardize each large data Apply one effort to standardize each large data stream and many practices and uses cash in on stream and many practices and uses cash in on the same effortthe same effort

Can find and route public health data to public Can find and route public health data to public healthhealth

Assume one standardized output for office-Assume one standardized output for office-based medical recordsbased medical records

With central repositoryWith central repository1.1. The LHII can The LHII can bebe the medical record the medical record2.2. The LHII can also serve authorized research usesThe LHII can also serve authorized research uses


Who contributes dataWho contributes data

Five major Indianapolis hospital systems Five major Indianapolis hospital systems (14 hospitals) 95% of hospital and ER (14 hospitals) 95% of hospital and ER carecare

Three (so far) hospital associated group Three (so far) hospital associated group practicespractices

Four homeless clinicsFour homeless clinics Public health departmentsPublic health departments

Immunization recordsImmunization records Public health department lab resultsPublic health department lab results Tumor registry (de-identified research only)Tumor registry (de-identified research only)


State Board of Health

County Health Department

Quest

LabCorp


All hospitals contribute – at All hospitals contribute – at least least

Discharge summaries/admissions Discharge summaries/admissions summariessummaries

Operative notesOperative notes Radiology reportsRadiology reports Pathology reportsPathology reports Cardiology reportsCardiology reports Tumor registry dataTumor registry data 2/5 – so far -- contribute MUCH MORE 2/5 – so far -- contribute MUCH MORE Public health contributes data tooPublic health contributes data too


How does the data flow from source to LHII repository –

HL7 Messages delivers most of the clinical data.

DICOM for radiology images

NCPDP for outpatient pharmacy

LOINC – Provides standard codes that defines the content of each delivered result.

http://www.regenstrief.org/loinc


Data flow to Data flow to repository repository

clinicalMessage

Map Code to LOINC

Standardized Institutional

Vault

Institutional Source


Storage & Message Volumes – Storage & Message Volumes – 06/0406/04

# HL7 message streams# HL7 message streams 84 ( 2 DICOM streams, 1 NCPD 84 ( 2 DICOM streams, 1 NCPD

# HL7 messages per # HL7 messages per yearyear

52 million52 million

# observation rows total # observation rows total 489 million489 million

# new observations/per # new observations/per yr yr

81 million 81 million

# text (dictated) reports # text (dictated) reports total total


# CPOE orders stored # CPOE orders stored (wish) (wish)


# EKG tracings stored# EKG tracings stored 480 thousand480 thousand

# Radiology images total# Radiology images total 45 million ( 2 systems)45 million ( 2 systems)

# Radiology images # Radiology images new/yr new/yr

25 million ( 2 systems)25 million ( 2 systems)

Document image Document image pointers/yr pointers/yr

13 million ( 1 system)13 million ( 1 system)


Don’t make it more Don’t make it more complicatedcomplicated HL7 vs. 2.X works just fineHL7 vs. 2.X works just fine Problems all come from flagrant dis-Problems all come from flagrant dis-

regard of the HL7 Specs e.g:regard of the HL7 Specs e.g: Coded data sent without codes or Coded data sent without codes or

coding system –(Just text)coding system –(Just text) Units put in value field instead of units Units put in value field instead of units

fieldfield Technical improvements can’t fix thisTechnical improvements can’t fix this


Limits Limits

Only have outpatient prescriptions Only have outpatient prescriptions for about 20% of the city- Working for about 20% of the city- Working with RX Hub to get much morewith RX Hub to get much more

Many large practices still to add Many large practices still to add


Who usesWho uses CliniciansClinicians

For ER patients in any of 14 emergency rooms. For ER patients in any of 14 emergency rooms. (expanding to much larger group)(expanding to much larger group)

Patients in institutions where clinicians have Patients in institutions where clinicians have admission privileges ( virtual record )admission privileges ( virtual record )

Patients with reports related to clinician. Patients with reports related to clinician. Unified electronic report delivery (200 office Unified electronic report delivery (200 office sites (30% of city) so far Scheduled to include sites (30% of city) so far Scheduled to include most of city by end of 2005most of city by end of 2005

Public health Public health reportable diseasesreportable diseases ImmunizationsImmunizations bioterrorismbioterrorism

Researchers – Pyloric stenosisResearchers – Pyloric stenosis


Provides a Health Provides a Health Information Infrastructure Information Infrastructure ** Broad capabilities for clinical care Broad capabilities for clinical care Research (cancer biology and Research (cancer biology and

epidemiologyepidemiology Public Health Public Health

* Report and Recommendations from the National Committee on Vital and Health Statistics. Information for Health: A Strategy for Building the National Health Information Infrastructure. Washington, DC, November 15, 2001.


INPC Storage StrategyINPC Storage Strategy

Central Community repository - Central Community repository - ESSENTIALESSENTIAL

Separate medical record vault per institutionSeparate medical record vault per institution

Each vault in separate physical filesEach vault in separate physical files

Standardized data structure – All use same Standardized data structure – All use same

software and observation codes . software and observation codes .

Combine on the fly when neededCombine on the fly when needed

Patient linkingPatient linking


INPC database INPC database organizationorganization

St. Vincent’s Community

Hospitals

Wishard

ClarianHealth

GlobalPatientIndex

Dictionary

MCHD

GlobalDoctor

File

ReportableConditions

St.Francis

LabCorp


INPC and ER CareINPC and ER Care

Patient checks into ERPatient checks into ER HL7 message to INPC ComputersHL7 message to INPC Computers Computer delivers précis of key Computer delivers précis of key

ER data printed in Index ERER data printed in Index ER Provides ER MD’s look-up access Provides ER MD’s look-up access

to all INPC content for 24 hoursto all INPC content for 24 hours


INPC Data AccessINPC Data Access


How it looks from the web How it looks from the web

Merged patient viewsMerged patient views Browser basedBrowser based How data from “another” institution How data from “another” institution

are footnoted on screen and printed are footnoted on screen and printed outputoutput

Access logsAccess logs


Flow sheet for blood count


Radiology Images - Thumbnail


BIG


BIGGER


BIGGEST 2800 x 2000


Report delivered to office Report delivered to office practicespractices


Report delivery to office Report delivery to office practicespractices 200+ practices (1000 MDs) at 200+ practices (1000 MDs) at

presentpresent Scheduled for whole city by end of Scheduled for whole city by end of

20052005


INPC’s Public Health GoalINPC’s Public Health Goal

Link clinical activities and public health activities to improve the population’s

health(Pluck reportable cases

from H L7 streams )


To InfectionControl

To InfectionControl

Reportable condition Reportable condition processorprocessor

InboundInboundHL7HL7

InboundInboundHL7HL7

PotentiallyReportablePotentiallyReportable

ReportableCondition

ReportableCondition

To PublicHealth

To PublicHealth

ReportableConditionsDatabases

ReportableConditionsDatabases

Abnormal flag,Organism name in Dwyer II, or Value above threshold

Compare to Dwyer Table I content (LOINC codes)

Record Countas denominator

E-mailSumma

ryRealtime Daily Batch

PrintReports


OutcomesOutcomes

ReliableReliable Real time deliveryReal time delivery 100%received (for participants)100%received (for participants)

Reporting completeness Reporting completeness (capture/recapture)(capture/recapture) Greatly increased case reportingGreatly increased case reporting

Reporting timeliness (versus result Reporting timeliness (versus result date)date) 8.4±15.4 days faster than HD8.4±15.4 days faster than HD 1.4±2.0 days faster than hospital1.4±2.0 days faster than hospital


De-Identified Research De-Identified Research

SPIN project SPIN project NCI funded Collaboration among NCI funded Collaboration among

IU/Regenstrief Harvard, U of IU/Regenstrief Harvard, U of Pittsburgh UCLAPittsburgh UCLA

De-identified cancer researchDe-identified cancer research Main aim is to provide access to Main aim is to provide access to

pathology reports and paraffin blocks pathology reports and paraffin blocks via searches on full medical record. via searches on full medical record.


Specify CohortSpecify Cohort


Specify statistical Specify statistical breakdownsbreakdowns


One way to show output as One way to show output as breakdownsbreakdowns


As we solve the user As we solve the user authentication problem, authentication problem, opportunities are vastopportunities are vast

All providers could have EMR at All providers could have EMR at miniscule costminiscule cost

Unmatched database for clinical Unmatched database for clinical research that could improve research that could improve population basepopulation base

Pervasive options for feedback and Pervasive options for feedback and reminders to MDreminders to MD


AcknowledgementAcknowledgement

Support fromSupport from National Library of MedicineNational Library of Medicine National Cancer InstituteNational Cancer Institute Regenstrief FoundationRegenstrief Foundation Lilly INGEN grant Lilly INGEN grant

implementation (an lhii supporting care, public health and research in indianapolis ) clem mcdonald,...

Documents

data u

highway u

u hospital

effort u

users u

road u

years u

public health u