Shan He, PhD Intermountain Healthcare Implementing Automated Data Reporting to Improve Early Hearing Care S116: Methods for Enhancing Public Health Surveillance with EHR Data Shan He, PhD Intermountain Healthcare

Disclosure I have no relevant relationships with commercial interests to disclose. AMIA 2017 | amia.org

Introduction Hearing loss is one of the most common birth defects (1 out of 300 babies) The first months and years of life are a critical period for brain development. Early identification of hearing loss and appropriate intervention ensures a child will have the opportunity to reach their maximum potential source: http://health.utah.gov/cshcn/programs/ehdi.html AMIA 2017 | amia.org

Early Hearing Detection and Intervention (EHDI) LTD Public Health Healthcare Provider Test for congenital CMV Child Birth Newborn Hearing Screening Repeat Hearing Screening Discharge Outpatient Hearing Screening fail fail fail LFU Diagnostic Hearing Evaluation Day 1 Day 2 Day 3 Day 14 Day 21 3 months LFU: loss to follow-up; LTD: loss to documentation AMIA 2017 | amia.org

Background 2014 Annual EHDI data indicate about 34% of infants were considered as LFU/LTD1 Utah: 13% of infants were considered as LFU/LTD 1Source: Summary of Diagnosis and Loss to Follow-up / Loss to Documentation in 2014 https://www.cdc.gov/ncbddd/hearingloss/ehdi-data2014.html AMIA 2017 | amia.org

Objective Enable real-time, electronic diagnostic hearing data reporting to the State EHDI program Implement a solution with low budget by leveraging existing Health Information Exchange (HIE) infrastructure AMIA 2017 | amia.org

Methods Develop decision support rules to capture the diagnostic evaluation event in real-time Generate a standard C-CDA document with embedded diagnostic evaluation report and lab results Send the C-CDA document to the State EHDI program using Direct email AMIA 2017 | amia.org

Data Flow Overview AMIA 2017 | amia.org

Decision Support Triggers 1 2 3 Decision Support Triggers Data-driven Storage of a CMV lab result Finalized documentation of a diagnostic evaluation report Audiology Assessment/Reassessment Audiology Audiogram Report, Pediatric Audiology External Medical Information, Pediatric Audiology Auditory Brainstem Response Report, Pediatric Audiology Assessment Audiology Consult Audiology Evaluation Report, Pediatric Audiology Oto Acoustic Emissions Report, Pediatric Audiology Initial Evaluation Report Audiology Progress Report, Pediatric Audiology Initial Evaluation Report, Pediatric Audiology Tympanogram Report, Pediatric Cytomegalovirus DNA [Presence] in Unspecified specimen by Probe & target amplification method 5000-5 Cytomegalovirus IgG Ab [Units/volume] in Serum by Immunoassay 5124-3 Cytomegalovirus IgM Ab [Units/volume] in Serum by Immunoassay 5126-8 Cytomegalovirus DNA [Units/volume] (viral load) in Plasma by Probe and target amplification method 72493-0 Cytomegalovirus DNA [#/volume] (viral load) in Unspecified specimen by Probe & target amplification method 33006-8 Cytomegalovirus DNA [Log #/volume] (viral load) in Unspecified specimen by Probe & target amplification method 53763-9 Cytomegalovirus DNA [Units/volume] (viral load) in Unspecified specimen by Probe and target amplification method 34720-3 Cytomegalovirus AMIA 2017 | amia.org

C-CDA Generation 1 2 3 Why C-CDA Progress Note Industrial standard for document-based health information exchange Existing C-CDA implementation infrastructure in place at Intermountain Progress Note is clinically suitable The C-CDA Progress Note can accommodate all information for this use case without requiring other irrelevant data types Assessment and Plan section—diagnostic report as image Results section—CMV lab results AMIA 2017 | amia.org

Embedded free-text report in C-CDA Identification of the CDA-R2 syntax and finding a way to present the JPEG information in the CDA document ( a simpler, standard one-step rendering process) AMIA 2017 | amia.org

Document Transport 1 2 3 Direct Secure, easy-to-use, inexpensive Existing Direct infrastructure implemented at Intermountain A Direct address was provisioned for EHDI by the state HIE Content sent as XML and rendered in human readable format Easy to parse, ready to be integrated with the HiTrack system as the next step AMIA 2017 | amia.org

Results AMIA 2017 | amia.org

Results AMIA 2017 | amia.org

Results Timeframe: 10/01/2016—09/30/2017 4,421 C-CDA documents sent from Intermountain to UDOH 2,236 unique patients 7% (158/2,236) of patients have both CMV and Audiological Note triggered C-CDA documents AMIA 2017 | amia.org

Results Number of C-CDA documents Month AMIA 2017 | amia.org

Results Number of C-CDA documents Age Group AMIA 2017 | amia.org

Results Frequency Number of C-CDA Hearing Documents per Patient About half of the patients have had more than one diagnostic event in one year. AMIA 2017 | amia.org

Outcome/benefits Reduced the LTD rate to near zero for Intermountain facilities from 12 reports/month (fax) to 368 reports/month (electronic) Decrease in LTD will impact the LFU, which in turn impacts early identification Faster intervention possible from EHDI Utah EHDI Program was able to quickly identify a child that received the wrong CMV test and contact the Primary Care Provider to conduct the right test within the 21 day time frame for proper treatment AMIA 2017 | amia.org

Limitations Non-structured data for the diagnostic audiology notes in C-CDA IHE Early Hearing Care Plan (EHCP) Profile under development Disconnection between the C-CDA documents received via Direct and the HiTrack system Lack of a formal evaluation of the completeness and timeliness of the electronic reporting AMIA 2017 | amia.org

Yesterday… Public Health Healthcare Provider LTD Public Health Healthcare Provider Test for congenital CMV Child Birth Newborn Hearing Screening Repeat Hearing Screening Discharge Outpatient Hearing Screening fail fail fail LFU Diagnostic Hearing Evaluation Day 1 Day 2 Day 3 Day 14 Day 21 3 months LFU: loss to follow-up; LTD: loss to documentation AMIA 2017 | amia.org

Today… Public Health Healthcare Provider Test for congenital CMV Child Birth Newborn Hearing Screening Repeat Hearing Screening Discharge Outpatient Hearing Screening fail fail fail LFU Diagnostic Hearing Evaluation Day 1 Day 2 Day 3 Day 14 Day 21 3 months AMIA 2017 | amia.org

Tomorrow… Public Health Healthcare Provider Test for congenital CMV Child Birth Newborn Hearing Screening Repeat Hearing Screening Discharge Outpatient Hearing Screening fail fail fail LFU Diagnostic Hearing Evaluation Day 1 Day 2 Day 3 Day 14 Day 21 3 months AMIA 2017 | amia.org

Acknowledgement Sidney N. Thornton, PhD, Intermountain Healthcare Darren Mann, Intermountain Healthcare Christine Perfili, MBA, Utah Department of Health Krysta Badger, Utah Department of Health Matt Hoffman, MD, Utah Health Information Network Viral Shah, Intermountain Healthcare Gary Anderson, Intermountain Healthcare Rishabh Bhatia, Intermountain Healthcare AMIA 2017 | amia.org

Thank you! shan.he@imail.org