Public Health IT Encouraging adoption/use of population health functions for EHRs and Consumer functions for PHRs This material (Comp13_Unit10) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC

Encouraging adoption/use of population health functions for EHRs and Consumer functions for PHRs Learning Objectives 2 Identify and describe population health functions of EHRs Describe the meaningful use criteria that are applicable to public health, population health, disease management and prevention Provide examples of common PHR systems (Microsoft HealthVault, Vendor- specific PHRs) and identify embedded consumer functions Define EHR adoption and use, with a focus on fidelity to public health goals Describe the challenges in and barriers to adoption and use of population health functions for EHRs and Consumer functions for PHR Explain and apply a rationale that would encourage adoption and use of public health functions for EHRs and Consumer functions for PHR Demonstrate the ability to formulate a plan to encourage adoption and use of population health functions for EHRs and Consumer functions for PHR, given a setting, population and workflow environment Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Population Health Functions of EHRs Identify and describe population health functions of EHRs 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

What is ‘Population Health’? 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Relatively new termHas its origins in CanadaDebate over exact emphasis or precise definition exists Is it a ‘concept of health’ or a ‘field of study of the determinants of health’ Population Health not synonymous to Public Health

Population Health Model 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Patterns of health determinants over the course of life Health outcomes and distribution in a population Policies and interventions at the social and individual levels

Definitions 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions An outcome oriented definition “The health outcomes of a group of individuals, including the distribution of such outcomes within the group” Broad definition “health of a population as measured by health status indicators and as influenced by social, economic, and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services.”

Definitions (cont.) 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Population Health = Population + HealthPopulation can have varying scope Clinic, Hospital Community, City, State Ethnic, Socio-economic Health can be defined to include both absence of disease and well being

Population Health and Public Health 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Population health has broader emphasis than how public health is usually defined Public health defined as a set of government agencies that work to “assess” and “assure” the conditions that are needed to maintain healthy societies

Population Health Measures 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Determinants or Process Measures Disease specific (number of mammograms) Smoking counseling rates Outcome measures Usually summative aggregate measures Some candidates Quality Adjusted Life Expectancy (QALY) Years of Healthy living Health Adjusted Life Expectancy (HALE)

EHR Functions for Population Health 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions EHRs can support assessment of several population health measures Determinant Measures Smoking rates Screening services dispensed Socio-economic measures Outcome measures Lesser support

EHR Functions for Population Health (cont.) 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Functional components of EHR that support population healthGuideline driven decision support modules Alerts to enable preventive screening Forms for disease specific data capture Registry functions Able to create or query for a population of patients Reporting functions Create reports for different measures

EHR Population/Public Health Functions (eClinicalWorks, 2010.) 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

EHR Population/Public Health Functions (cont.) (eClinicalWorks, 2010.) 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Learning Objective: Meaningful Use Describe the meaningful use criteria that are applicable to public health, population health, disease management and prevention 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Meaningful Use 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions A set of measures released by the Center for Medicaid Services to demonstrate “meaningful use” of EHRs Would apply to eligible providers and eligible hospitalsFocus on Safety, quality, efficiency Clinical Outcomes, prevention Patient empowerment Requirement to comply with 15 measures and more in stages from

Public Health Meaningful Use Measures (CMS, 2010.) 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Preventive Screening Measures in Meaningful Use 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Cervical ScreeningSmoking status and cessation counselingBreast Cancer ScreeningColorectal Cancer ScreeningDiabetes urine screening

Population Health Meaningful Use Measures Asthma Assessment Appropriate Testing for Children with Pharyngitis Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) Hypertension: Blood Pressure Measurement Prenatal Care: Anti-D Immune Globulin Controlling High Blood Pressure Weight Assessment and Counseling for Children and Adolescents Smoking and Tobacco Use Cessation, Medical assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies Preventive Care and Screening Measure Pair: a.Tobacco Use Assessment Preventive Care and Screening Measure Pair: b.Tobacco Cessation Intervention Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening for Women Colorectal Cancer Screening Use of Appropriate Medications for Asthma Childhood immunization Status Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old Pneumonia Vaccination Status for Older Adults 1.1 Table: Khan, S (2010). 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Population Health Meaningful Use Measures Asthma Pharmacologic Therapy Low Back Pain: Use of Imaging Studies Diabetes: Eye Exam Diabetes: Foot Exam Diabetes: HbA1c Poor Control Diabetes: Blood Pressure Management Diabetes: Urine Screening Diabetes: LDL Management & Control Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Ischemic Vascular Disease (IVD): Blood Pressure Management Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control Heart Failure (HF) : Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure (HF) : Warfarin Therapy Patients with Atrial Fibrillation Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Anti‐depressant medication management: (a) Effective Acute Phase Treatment, (b)Effective Continuation Phase Treatment Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Adult Weight Screening and Follow-Up Diabetes: HbA1c Control (<8%) 1.2 Table: Khan, S (2010). 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Personal Health Records and Their Functions Provide examples of common PHR systems (Microsoft HealthVault, Vendor- specific PHRs) and identify embedded consumer functions 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Everyday Life Situations 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions A cancer specialist in San Francisco wants to see your mother’s latest CT scan results for a second opinion. You live in New York and your mother in Florida. You are on vacation in the Bahamas and suddenly need to access your medical records in Boston You want to share your child’s immunization history with your doctor or other family members Several such everyday life situations where having your health information readily is a must

What is a Personal Health Record (PHR)? 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Markle Foundation defines a PHR as: “electronic application through which individuals can access, manage and share their health information and of others for whom they are authorized, in a private, secure and confidential environment”

The Promise of PHRs “We contend that PHRs are a disruptive innovation that inverts the current approach to medical records in that they are created by and reside with patients who grant permission for their use to institutions, clinicians, researchers, public health agencies, and other users of medical information.” - Mandl and Kohane 23 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

And the Growing Buzz “..tectonic shift in health information economy” One of the meaningful use criteria requires that patients be given summaries of their visit in electronic format Consumer surveys show that 79% of Americans believe that online PHRs could be of benefit 24 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

What does a PHR Provide? 25 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions View information Laboratory test results Medications prescribed Diagnosis Actions Request appointments Refill requests providers Self data input

Types of PHRs 26 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Simple DiariesPen (USB) drive based PHRsPart of an Electronic Health RecordInternet-based PHRs – offered by Health plans Employers Consumer websites

The Emerging Generation of PHRs PHRs involving into Personal Health Record Platforms such as Microsoft HealthVault Indivo, Dossia Project HealthDesign (Microsoft HealthVault, 2010.) 27 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

28 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions The Emerging Generation of PHRs (cont.) The key difference of these PHR platforms Backend integration with several healthcare organizations Open to third-party applications hence more than a data repository Interoperable Allow easy sharing of data between humans and third-party applications

Important Elements of PHR Platforms 29 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Allow patients to import data from their provider or healthcare organizations Give them control to manage their informationProvide them applications that extend the use of the PHRLet them share information with trusted peopleMaintain security and privacy

Quick Tour of HealthVault (Public Domain, 2011.) 30 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

HealthVault - Creating a Record (Health Vault, 2011.) 31 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

HealthVault - Application Directory (Health Vault, 2011.) 32 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

HealthVault - PHR Change Log (Health Vault, 2011.) 33 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

HealthVault - Completing a H1N1 Assessment (Health Vault, 2011.) 34 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Inside HealthVault -Granting Consent (Health Vault, 2011.) 35 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

PHRs and Privacy/Security Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Patient-control is a fundamental aspect of these new PHR platforms HealthVault HIPAA doesn’t (yet) cover PHRs such asLaws may however change

EHR Adoption Define EHR adoption and use, with a focus on fidelity to public health goals 37 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Adoption of Population/Public Health Functions 38 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Population Health Functions Low adoption Mostly Limited to reporting Public Health - Syndromic Surveillance Reports to Health Plans JCAHO compliance Internal quality audits

39 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Adoption of PHRs PHR adoption till now has been limited - Surveys put this number between 3-7% Markle Foundation survey - approx 3% Latest CHCF report says 7% adoption Few clear successes Kaisers Permanente’s MyChart program 3 million regular users, 8.5 million registered users More than 4 million messages sent Veterans Affairs PHR has 650,000 users

Challenges and Barriers to Adoption of Population Health Functions Describe the challenges in and barriers to adoption and use of population health functions for EHRs and Consumer functions for PHR 40 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Challenges and Barriers 41 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Population Health Function Use Financial Incentive Not enough incentives for keeping people well Time Pressures Average visit less than 15 minutes long Preventive and behavioral change measures not given priority

Challenges to Population Health 42 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Population Health Function Use EHR Systems not adequately designed Difficult to get doctors to comply with guidelines Most physician ignore reminders about guideline directed recommendations Patient’s Responsibility Beyond Providers Achieving healthy outcomes also depends on patients and their lifestyle and choices

Adoption of PHRs 43 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Challenges and Barriers Issues related to Data Limited data Inaccurate or unclear data Not always integrated with clinical care Limited use cases or useful “things to do” Privacy concerns 67% of people surveyed expressed concern about privacy of their data

Explaining and Applying Rational to Public Health Functions Explain and apply a rationale that would encourage adoption and use of public health functions for EHRs and Consumer functions for PHR 44 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Encourage Adoption of Population Functions 45 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Increase financial incentives for preventive and population health outcomes Decrease burden of data collection Improved report creation EHR system improvements

Encourage Adoption of PHRs 46 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Be able to get a summary either in , USB drive, or in the PHR of their choice Provide patients access to their data in the “way they want it” and not locked into a specific system Build reader to read and display summary docs and import them into the PHR platforms

Encourage Adoption of PHRs (cont.) 47 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Encourage third party developers to make the applications that can then sit on top of the PHR platforms to add value PHR application development contest

Formulating a Plan to Encourage Adoption of Population Health Functions Demonstrate the ability to formulate a plan to encourage adoption and use of population health functions for EHRs and Consumer functions for PHR, given a setting, population and workflow environment 48 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions

Settings 49 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Clinic using EHR to monitor HbA1cs for Diabetes management A Hospital can use the EHR for monitoring the compliance with screening services Parent of a 1 yr old can use the PHR to track their child’s immunization history

Encouraging adoption/use of population health functions for EHRs and Consumer functions for PHRs Summary 50 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions Population health is about improving the outcomes of health in a population EHRs can be used to achieve population health objectives though adoption is low PHRs can enable patients to better manages their health information, but barriers remain

Encouraging adoption/use of population health functions for EHRs and Consumer functions for PHRs References References: 1.Kindig D, Stoddart G. What Is Population Health? Am J Public Health March; 93(3): 380– Mandl, K.D., Kohane, I.S. (2008). Tectonic SHifts in the health information economy. New England Journal of Medicine, 358: Retrieved on October 1st, 2010 from Retrieved on October 1 st, 2010 from 4.Retrieved on October 1 st, 2010 from information-technology-a-national-survey. information-technology-a-national-survey 5.Retrieved on October 1 st, 2010 from 6.Retrieved on October 1 st, 2010 from TOC.pdf. TOC.pdf Images Slide 12& 13: Buck, M. (2010). Images of desktop- systems of eclinicalworks system. New York Department of Health and Mental Hygiene, Primary Care Information Center. Slide 16: Retrieved on October 1 st, 2010 from Slide 27: Image of Microsoft HealthVault. Retrieved on October 1 st, 2010 from Slide 30-35: Images Retrieved on October 1 st, 2010 from Charts, Tables, Figures 1.1 & 1.2 Table: Khan, S. Population health meaningful use measures-list. Department of Biomedical Informatics. Columbia University Medical Center. 51 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Adoption and Use of Population Health Functions