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Popula’on Health, Public Health, & Meaningful Use James W. Buehler, MD Health Commissioner Philadelphia Department of Public Health Delaware Valley Chapter HIMSS January 29, 2015 1

Populaon)Health,)Public)Health,) &)Meaningful)Use)...Populaon)Health,)Public)Health,) &)Meaningful)Use) James&W.&Buehler,&MD& Health)Commissioner) PhiladelphiaDepartmentof)Public)Health)

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Page 1: Populaon)Health,)Public)Health,) &)Meaningful)Use)...Populaon)Health,)Public)Health,) &)Meaningful)Use) James&W.&Buehler,&MD& Health)Commissioner) PhiladelphiaDepartmentof)Public)Health)

Popula'on  Health,  Public  Health,  &  Meaningful  Use  

James  W.  Buehler,  MD  Health  Commissioner  

Philadelphia  Department  of  Public  Health  

Delaware  Valley  Chapter  HIMSS  January  29,  2015  

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Overview:  What  are  the  connec'ons  across  Public  Health,  Popula'on  Health,  &  

Healthcare?  

•  Phila.  Dept.  of  Public  Health:  Who  are  we?  •  How  is  our  shared  landscape  evolving?  •  What  are  the  impacts  of  

– Meaningful  Use  – Affordable  Care  Act  

•  Where  are  we:  public  health  repor'ng  &  MU?  •  What’s  on  the  horizon?  

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PDPH  Vision  &  Mission  

•  Our  vision  is  of  a  city  in  which  every  resident  is  able  to:  –  Live  a  long,  healthy,  and  produc've  life;    –  Be  free  of  preventable  disease  and  disability;  and  –  Live,  work,  learn,  shop,  and  play  in  environments  that  promote  

health.  

•  Mission:  To  protect  and  promote  the  health  of  all  Philadelphians  and  to  provide  a  safety  net  for  the  most  vulnerable.  

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•  Environmental  Health  –  Restaurant  inspec'ons,  vector  control,  

lead  poisoning  preven'on  

•  Air  Management  Services  –  Air  quality  monitoring,  regula'on,  

commercial  noise  control  

•  Disease  Control  –  STD,  TB,  flu,  outbreak  response,  

disease  monitoring,  emergency  preparedness  

•  AIDS  AcBviBes  CoordinaBng  Office  –  Preven'on,  screening,  treatment  

•  Chronic  Disease  PrevenBon/Get  Healthy  Philly  

–  Tobacco  control,  obesity  preven'on  

•  Maternal,  child,  &  family  health  −  Home  visi'ng,  breas[eeding  

•  Medical  Examiner’s  Office  

−  Autopsies,  fatality  review  programs,  bereavement  support  

•  Public  Health  Lab  −  Clinical,  public  health,  emergency  

preparedness  

•  Ambulatory  Health  −  8  primary  care  health  centers,  EHR  

rollout  

Public  Health  is  Popula'on  Health:  PDPH  opera'onal  divisions  

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Policy  

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Health  Promo'on  &  Protec'on:  Programs  &  Partnerships  

6  

Opening  of  New  Neighborhood  Farmers  Market  Chris'an  Street  YMCA,  September  2014  

Image:  Green  Mountain  Energy    

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Pa'ent  Care  Services  

7  Health  Federa'on  Youth  Poster  Compe''on,  2014  

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HIT,  HIE,  &  QI:  Long-­‐term  trends  accelerated  by  Meaningful  Use    

•  Beher  informa'on  for  pa'ent  care  •  Beher  informa'on  about  popula'on  health  

–  People  enrolled  in  an  insurance  program  –  Pa'ents  under  care  of  a  provider  –  People  in  a  poli'cal  jurisdic'on  – We  need  to  know:  

•  What  is  the  health  of  our  “popula'on?”  •  How  well  are  we  doing  our  job?  

–  Requirements  of  interest  to  public  health:  •  ReporBng  to  health  departments:  PopulaBon  health  monitoring  •  Promote  use  of  preven've  services:  prompts  and  QI  measures  •  Decision  support  

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Public  Health  Repor'ng  in  Meaningful  Use  

•  Disease  surveillance  – Monitor  trends  –  Characterize  at-­‐risk  popula'ons  –  Iden'fy  urgent  situa'ons  –  Inform  programs  – Meaningful  Use:  

•  Lab  results  for  reportable  condi'ons  •  “Syndromic”  surveillance  •  Immuniza'on  registry,  aka  Immuniza'on  Informa'on  System  (IIS)  

•  Cancer  registry  (new,  in  Stage  2)  

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Disease  Repor'ng  Mandated  by  State  Law  www.health.state.pa.us    

•  Physicians,  clinics,  hospitals,  laboratories  •  Lab-­‐ini'ated  repor'ng  for  infec'ous  diseases  

–  Promotes  'meliness  &  completeness  –  Focus  on  large  commercial  labs  (predates  MU)  –  S'll  need  remainder  of  clinical  info  

•  Meaningful  Use  –  Hospitals:  Lab  results  for  reportable  condi'ons  

•  Onboarding  &  ahesta'on:  Via  State  Health  Dept.        •  No  Phila.  Hospitals  yet  onboarded  

–  Future:  fully  automated  case  repor'ng  (clinical  &  lab  info)    •  ONC  did  not  select  for  inclusion  in  Stage  3  •  Focus  of  ac've  development  

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Electronic  Laboratory  Repor'ng  Data  Managed  More  Quickly  

0%  

20%  

40%  

60%  

80%  

100%  

%  Cases  thru  ELR  

2010   2011   2012   2013  

0  

3  

6  

9  

12  

Mean  #  Days  'l  Ac'on  

2010   2011   2012   2013  

Example:  Summer  2013  Salmonella  outbreak  associated  with  catered  lunches  detected  in  2-­‐3  days  aqer  onset  of  illness   12  

All  reportable  diseases   Salmonella  cases  

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Automated  Repor'ng:    High  Volume  Diseases  Can  Be  Addressed  

11,140  12,820  

14,539  

19,785  

0  

4,000  

8,000  

12,000  

16,000  

20,000  

24,000  

2010   2011   2012   2013  

PosiBve  HCV  Test  Reports  

Impact:  Faster  recogni'on,  detec'on,  &  inves'ga'on  of  acute  infec'ons   13  

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Philadelphia  Immuniza'on  Registry:  KIDS  Plus  

•  Philadelphia  and  State  Registries  •  Ahesta'on  via  both  registries  

•  Providers  in  Phila.  required  to  report  to  Phila.  KIDS  Plus  (Child  &  Adult)  

•  State  downloads  reports  to  Phila.  KIDS  Plus  

•  Phila.  to  state  uploads  (under  development)  

•  KIDS  Plus  Data  collec'on:  •  HL7  Interface  –  2.3.1  and  2.5.1  

•  Billing  or  EMR  delimited  files  

•  Direct  entry  

•  Paper  logs  

•  Methods  of  transport:    •  Batch  messaging  to  sFTP  

•  SOAP  web  services  

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KIDS  Plus:  Improved  Timeliness  

2012   2014  

Overall   33   23  

HL7  “Real  Time”   N/A   0  

HL7  Daily  Batch   N/A   2  

EMR  Flat  File  (~monthly)   25   35  

Billing  (~monthly)   39   35  

Manual  (in  house)   78   14  

Median  Number  of  Days  between  Vaccina'on  and  Entry  into  KIDS  Plus  

•  Populated  using  weekly  feed  from  state  e-­‐birth  cer'ficates  •  >1,000  Ac've  Users  (providers,  school  nurses,  prison  health,  shelters  •  ~45  providers  (of  165)  using  HL7  repor'ng  •  Backlog  of  adult  vaccina'ons  reported  via  insurers’  billing  records  •  State  forwards  into  for  Phila.  residents  

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KIDS  Plus  IIS  Repor'ng  Vaccina'on  Counts  (Cumula've  Jan-­‐Dec)  

by  Repor'ng  Method  2014  2012  

1.93  million  vaccina'ons  54%  received  through  HL7  

1.21  million  vaccina'ons  3%  received  through  HL7  

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Syndromic  Surveillance  

•  Rapid  snapshot  of  health  status  for  broad  syndrome  groups  •  Limited  data  collec'on:  demographics,  chief  complaint  or  

discharge  diagnosis  •  Hospital  ED:  most  common  source  •  Philadelphia:  “Home  grown”  system  started  in  2002  

–  Transi'oning  to  State  system  •  Operated  by:  Health  Monitoring  Systems,  Inc.  (HMS)  

–  Current:  16  via  HMS;  3  via  legacy  system    •  Meaningful  Use  

–  Onboarding  &  ahesta'on  via  State/HMS  –  Emphasis  on  hospital  EDs  –  No  funding  to  support  onboarding  for  outpa'ent  providers  

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Example:  Use  of  ED-­‐based  Syndromic  Surveillance  for  “Influenza-­‐Like  Illness”  in  Combina'on  with  Other  Data  hhps://hip.phila.gov/xv/    

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Repor'ng  to  Cancer  Registry  

•  Menu  Op'on  in  Stage  2  •  Managed  by  state  cancer  registry  

19  hhp://www.portal.state.pa.us/portal/server.pt/community/pa_cancer_registry/14280    

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CMS  Quality  of  Care  Measures  Align  with  Public  Health  Objec'ves  

Adults  •  Controlling  High  Blood  

Pressure  •  Tobacco  Use:  Screening  

and  Cessa'on  Interven'on  

•  Screening  for  Clinical  Depression  and  Follow-­‐Up  Plan  

•  Body  Mass  Index  (BMI)  Screening  and  Follow-­‐Up  

Children  •  Weight  Assessment  and  

Counseling  for  Nutri'on  and  Physical  Ac'vity  

•  Chlamydia  Screening,  16+  •  Childhood  Immuniza'on  

Status  •  Appropriate  Treatment  

for  URI  •  Children  who  have  dental  

decay  or  cavi'es  

20  hhp://www.cms.gov/Regula'ons-­‐and-­‐Guidance/Legisla'on/EHRIncen'vePrograms/2014_ClinicalQualityMeasures.html  

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American  Reinvestment  &  Recovery  Act,  2009  Health  InformaBon  Technology  for  Economic  and  Clinical  

Health  Act  (HITECH)  $33  Billion  

Source:  hhp://www.ahima.org/advocacy/arrahitech.aspx    

CMS  

NTIA  

DoA  

ONC  

HRSA  

AHRQ  

SSA  

I  H  S  

VA  

Page 22: Populaon)Health,)Public)Health,) &)Meaningful)Use)...Populaon)Health,)Public)Health,) &)Meaningful)Use) James&W.&Buehler,&MD& Health)Commissioner) PhiladelphiaDepartmentof)Public)Health)

Government  public  health  represents  3%  of  U.S.  health  spending  NaBonal  Health  Expenditures,  2014,  $3.1  Trillion  

Government  Public  Health  

All  other  

Source:  Centers  for  Medicare  and  Medicaid  Services.  Na'onal  Health  Expenditure  Projec'ons  2012-­‐2022.  hhp://www.cms.gov/Research-­‐Sta's'cs-­‐Data-­‐and-­‐Systems/Sta's'cs-­‐Trends-­‐and-­‐Reports/Na'onalHealthExpendData/Na'onalHealthAccountsProjected.html    

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Will  Meaningful  Use  be  meaningful  for  public  health?      

•  Required  repor'ng  easier  for  providers  •  Easier  for  public  health  staff-­‐-­‐allows  shiq  of    ahen'on  from  collec'ng  to  using  informa'on  

•  Fulfills  a  clear  PH  need  for  informa'on  •  Informa'on  provided  back  to  providers  and  public    

•  Value  and  impact  of  informa'on  is  apparent  •  Strengthens  healthcare-­‐public  health  collabora'on  

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www.poli'co.com  

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PDPH  Implemen'ng  EHR  in  network  of  8  primary  care  clinics  

•  Stages  –  Prac'ce  management  system  

–  Medical  record  

–  Interfaces  &  connec'ons,  including  regional  HIE    –  Analysis  capabili'es  

•  QI  &  performance  measures  

•  Research  (data-­‐use  policies)  •  Issues:    

–  Planning,  training,  accommoda'ons,  legacy  data,  upgrades  

–  Cultural  alignments  •  Informa'cs  •  IT  •  Clinical  •  Public  Health  

–  Integra'on  with  STD  &  TB  clinics  

•  Opportunity  to  model  new  healthcare-­‐public  health  collabora'on   25  

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Affordable  Care  Act:    Not  just  health  insurance  

•  Alignment  of  clinical  and  public  health  priori'es  

•  Importance  of  chronic  diseases    

•  Emphasis  on  con'nuity  of  care  –  Among  healthcare  providers  

–  Between  healthcare  &  the  community  

•  Example:  Role  of  Community  Health  Workers  

•  Community  health  needs  assessment  (CNHA),    response  implementa'on  plans  –  Not-­‐for-­‐profit  hospitals,  repor'ng  to  IRS  

–  CNHA:    •  Requires  engagement  of  state/local  PH  agency  (new)  •  Allows  for  collabora'on  and  sharing  of  community-­‐wide  assessments  

–  Response/implementa'on  •  Most  emphasize  un-­‐reimbursed  care  or  training  •  Small  percentage  of  investments  for  outside-­‐hospital  community  benefit  ac'vi'es  

•  New  opportuni'es  for  Healthcare  &  PH  collabora'on  –  Example:  Phila.  Community  Health  Improvement  Plan  –  www.phila.gov/health/commissioner/pha.html  

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Mul'ple  Chronic  Diseases  •  Aging  of  baby  boomers  •  Impact  on  healthcare  use  and  costs  •  Leading  contributor  to  premature  death  &  preventable  morbidity  •  Poverty  strong  determinant  of  poor  outcomes  •  Outcomes  affected  by:  

–  Healthcare  –  Home  &  community  situa'ons  

1980  &  2010  27  

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Improve health security at home and around the world

Better prevent the leading causes of illness, injury, disability, and death

Strengthen public health/ health care collaboration

CDC strategic directions

Health Care

Public Health

CDC,  2014,  www.cdc.gov  

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Example:  New  CDC-­‐funded  Project  to  Improve  Healthcare  &  Public  Health  Collabora'on  

•  Learning  collabora'on:  PDPH  +  40  prac'ces    –  FQHCs:  Health  Federa'on  of  Philadelphia  –  Hospital-­‐based:  Health  Care  Improvement  Founda'on  

•  Set  common  goals  (HEDIS-­‐based)  –  Disease  iden'fica'on,  medica'on  adherence,  disease  control  

•  Use  EHRs  to  monitor  care,  based  on  MU  requirements  •  Pa'ent  educa'onal  resources  •  Explore  models  for  engaging  community  health  workers  •  Primary  preven'on  

–  Diabetes  Preven'on  Program  to  Medicaid  beneficiaries  at  discount  (~$25)  –  Partnership  with  YMCA  –  CDC-­‐designed  16-­‐week  program  for  people  at  high  risk  for  diabetes.    –  Educa'on  on  diet  and  physical  ac'vity  –  Reduces  the  incidence  of  diabetes  

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Conclusions    

•  Kinship  between  healthcare  and  public  health  views  of  popula'on  health  – Accelerated  by  Meaningful  Use  and  ACA  

•  Progress  and  challenges  in  achieving  aims  of  Meaningful  Use  

•  Increasing  importance  of  healthcare  &  public  health  collabora'on  

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Page 31: Populaon)Health,)Public)Health,) &)Meaningful)Use)...Populaon)Health,)Public)Health,) &)Meaningful)Use) James&W.&Buehler,&MD& Health)Commissioner) PhiladelphiaDepartmentof)Public)Health)

For  addi'onal  informa'on  hhp://www.dhs.state.pa.us/provider/healthcaremedicalassistance/medicalassistancehealthinforma'ontechnologyini'a've/meaningfuluse/index.htm    

hhp://www.dhs.state.pa.us/cs/groups/webcontent/documents/document/p_039230.pdf    Philadelphia  

Immuniza'ons  Amira  Elhagmusa,  MPH    Tel:  215.685.6494  [email protected]  

Syndromic  José  Lojo,  MPH    Tel:  215.685.6849  [email protected]  

Claire  Newbern,  PhD  MPH  Tel:  215.685.6495                    [email protected]  

Pennsylvania  

Immuniza'ons  Frank  Caniglia  [email protected]    

Syndromic  Kirsten  Waller    [email protected]  

Hospital  Lab  Results  Mark  Dihman  [email protected]  

HIMS  –  syndromic  (outpa'ent)        Ben  Luffey    [email protected]  

Cancer  Registry  Wendy  Aldinger    [email protected]    


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