Electronic Health Records and Public Health

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Electronic HealthRecords

EHRs and Public Health Systems

SPH 210 - 2010



Overview

� The role of EHRs in public health

� Re-thinking public health in an electronichealthcar e world

� Augmenting public health with health IT

± Regional bed capacity planning andmanagement

± Disaster planning and management± Vital r ecords and EHRs

� Public Health and HIE



Role of EHRs in Public Health

� EHRs not typically consider ed a tool for enhancing public health

� Do they have a role?

± automating r eportable disease data collection

± acquiring data in structur ed, computable form

± monitoring disease patterns

syndromic sur veillance hospital admissions

discharge data

± quality improvement is a public health issue



Re-thinking Public Health

� Public health has tr aditionally beenconstr ained by the paper-based natur e of healthcar e data

� EHRs and HIEs dr amatically alter the information landscape and provide unpr ecedented opportunities for publichealth

� What should the role of public health departments be now that EHRs and HIEscarry significant amounts of health data in

computable electronic form?



What is the NHIN?

� ~ 2005 the ONC proposed a fr ameworkfor national data exchange ± the NationalHealth Information Network (NHIN)

� 2010 ± NHIN is oper ating as the ³NHINLimited Production Exchange´

± connects f eder al agencies and private

organiz

ations to

exc

hang

e

healt

hinform

ation

± SSA, MedVirginia, VA, DoD, Kaiser Permanente



NHIN CONNECT

� NHIN Connect is open source softwar e designedto support health information exchange at anenterprise level

� Originally developed by f eder al government to

support exchange among a select set of f eder alagencies

± over 20 f eder al agencies involved DHHS, AHRQ, CDC, CMS, FDA, HRSA, IHS, NIH, DoD,

DOE, EPA, DOT, VA, NASA, etc..

� Now softwar e is available to any organization

http://www.connectopensource.org/about/what-is-CONNECT



NHIN Connect Architecture

� Thr ee primary components± Cor e Ser vices Gateway

provides ability to locate patients at other organizations

r equest documents associated with a patient

mechanisms to evaluate authorizations for r elease of medical information

± Enterprise Ser vice Components set of key enterprise ser vices needed to support exchange

master patient index, Document r egistry and r epository, Authorization

policy engine, Consumer pr ef er ences manager, Audit log

± Universal Client Fr amework set of applications that can be adapted quickly to use NHIN

Connects gateway



NHIN Connect Capabilites (v2.3)� NHIN Connect v2.3 ± r eleased Jan 2010

� Content± HITSP C.32 Summary of Car e document

± CARE Profile

± GIPSE Profile

� Ser vices

± Patient Discovery

± Document Query

± Document Retrieval

± Consent Management

± Audit Logging

± Health Information Event Messaging± Authorized Case Follow-Up

± Document Submission\

� A link to the NHIN Connect specifications:± http://developer.connectopensource.org/display/NHINR231/NHIN+Specification+Ref er ences



NHIN Security

� NHIN nodes must authenticate each other and encrypt information exchangedbetween them

� Accomplished using public keyinfr astructur e (PKI) to cr eate secur e channels between NHIN nodes using

stand

ard Int

ern

et

Tr

ansport L

ay

er S

ecurity(TLS)

NHIN Architectur e Over videw, v1.0. Jan 29, 2010



NHIN Messaging

� NHIN¶s common tr ansport layer

± messaging standards

± web ser vice protocols

� Specifications± SOAP 1.2

± WSDL 1.1

± WS-Addr essing 1.0± WS-Policy 1.5

± MTOM 1.0

NHIN Architectur e Over view, v1.0. Jan 29, 2010



NHIN Patient Discovery

� The initiating node sends a patient discovery r equest to one or mor e patient discovery web ser vice end points for targetNHIN nodes

� Each r esponding NHIN node attempts to match the set of demogr aphics provided with those in its own master person

index

� If a single match, the r esponding node sends the PatientIdentifier (PID).

� If a single match is not achieved, the target may r espond with an error condition which may either r equest additionalattributes or indicate a match cannot be achieved.

� The initiating node can take r esulting PIDs and performsubsequent patient-specific tr ansactions with the r emote NHIN node that has asserted a match for this person




NHIN Query and Retrieval of Documents

� Query for Documents allows an NHINnode to r equest a patient-specific list of available documents from a r emote node

�Subj

ect to

an

aut

horiz

ation d

ecision, t

he r esponding node r eturns a list of

document identifiers and other metadata associated with the documents

� The Retrieve Documents ser vicesr etrieves one or mor e of the documentsusing the Document Identifier




NHIN Health Information Event Messaging

� Allows an initiating NHIN node to establish a subscription to information held by a r esponding node for periodic exchange

± subscription: node sends a sub r equest tor esponding node. The r eceiving node gr antsthe r equest to establish the subscription

± notification: the r esponding NHIN node

notifies the subscriber as events occur which match the approved subscription criteria




NHIN Document Submission

� Allows an initiating node to send one or mor e documents for a given patient to a r eceiving node without a prior

query/r etrieve r equest� The r eceiving NHIN node may evaluate

the documents submitted and accept or

r eje

ct the

m,a

nd r eturn

an

Acc

ept or Reject status to the originating node




What is CARE?

�Continuity

Ass

essm

ent R

ecord

and E

valu

ation (C

ARE)

� Part of the CARE Health Information Exchange Project(C-HIEP)

� a data set being developed by CMS to promote data exchange in support of improving the quality of car e for patients as they tr ansition among providers

� Major Domains for CARE data set± Administr ative

± Medical, Health Status

± Cognitive, Mood, Pain± Impairment

± Functional status

± Plan of Car e

± Discharge, car egiver needs

http://www.ihe.net/Connectathon/upload/IHE_2010_NA_Connectathon_Conf er ence_Quality-CMS_MRice.pdf



What is GPSIE?

� GIPSE ± Geocoded Interoper able Population Summary Exchange

� GIPSE is a data format cr eated by the

CDC to allow electronic exchange of health condition summary data str atifiedby a number of variables, including

ge

ogr a

ph

y±

to support biosur ve

illanc

e

� GIPSE¶s data element descriptionsGeoLocation and GeoRegion information

NHIN Architectur e Over videw, v1.0. Jan 29, 2010



Virtual Lifetime Electronic Record (VLER)

� Aug 13, 2009 - Pr esident Bar ack Obama, Def ense Secr etary Robert M. Gates, and Veter ans Aff airsSecr etary Eric Shinseki, announced the VA and the Def ense Department wer e cr eating a joint virtual lif etime electronic r

ecord, or

VLER.

� VLER is a f eder ally funded initiative to exchange health information to provide a lif etime medical r ecord for ser vice members.

� Goal - to help pr event misplaced paperwork and helpproviders maintain and off er quality health car e for ser vice members

� A useful test case for NHIN Connect

http://fcw.com/Articles/2010/02/04/Def ense-Veter ans-VLER-Virtual-Lif etime-Electronic-Record.aspx?p=1



Examples of Public Health Functions

improved by EHR adoption

� Bed capacity

� Disaster planning

� Disaster management

� Improves statutorily mandated monitoring

± inf ectious disease

± lead levels

± cancer

� Improve vital r ecord r eporting



Public Health Advantages of HIE

� Improved timeliness of r eportable diseases

� Opportunity to identify gaps in pr eventive

health� Geogr aphic visualization of illness or injury

� Real-time display of tempor al and

geogr aphic disease r elated data on a dashboard

http://www.phii.org/r esources/doc_details.asp?id=117



Health Informatics and Public Health

� Mandated r eporting of labor atorydiagnoses

� Mandated r eporting of physician

diagnoses� Public health investigation

� Antibiotic r esistance sur veillance

� Population level quality monitoring

Shapiro. Evaluating public health uses of health information exchange. Journal of Biomedical Informatics 40 (2007)S46S49



State Health Information Exchange

Cooperative Agreement Program

� A progr am funded by HI-TECH (ARRA)

� Managed by ONC

� Goal:

± to develop and advance mechanisms for information sharing across the health car e system

� Provides $564 million to support ³efforts toachieve widespr ead and sustainable health information exchange within andamong states...´

http://healthit.hhs.gov/portal/ser ver.pt?open=512&objID=1333&par entname=CommunityPage&par entid=47&mode=2&in_ hi_userid=11113&cached=true#



State HIE Cooperative Agreements

� If funded, a state must:± develop and implement privacy and security r equir ements for

HIE

± develop dir ectories and technical ser vices to enable interoper ability within and across states

±coordin

ate

with

Medic

aid

and st

ate

publichea

lth

progr ams toenable information exchange

± r emove barriers that may hinder eff ective HIE

interoper ability across labs, hospitals, pr actices, health plans andothers.

± ensur

e an

eff

ecti

vemod

el for HIE go

vern

anc

e

and

accountability is in place

± convene health car e stakeholders to build trust andsupport for a statewide approach to HIE