Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Use of Real-Time Bidirectional Health Information Exchange and its Positive Impact on HIV-Related Outcomes Manya Magnus, PhD, MPH Associate Professor Department of Epidemiology and Biostatistics The George Washington University School of Public Health and Health Services 1 July 2013

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Acknowledgements (1) This study was funded in part by a grant from the Health Resources and Services Administration, Special Projects of National Significance within the HIV/AIDS Bureau, HRSA Grant #H97HA08476 The content of this presentation does not necessarily reflect the views or policies of DHHS/HRSA and responsibility for the content rests solely with the authors The authors have no conflicts of interest to report © Copyright 2009 Board of Supervisors of Louisiana State University and Agricultural and Mechanical College, through its LSU Health Sciences Center ALL RIGHTS RESERVED

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Acknowledgements (2) Jane Herwehe, Michael Kaiser, Luis Smith, Amir Abrams, Keith Verret, Wayne Wilbright, Ke Xiao – LSU HCSD Elizabeth Shepard, DeAnn Gruber, Joseph Foxhood, Amy Zapata, George Stephens, Beth Scalco, Debbie Wendell– OPH SHP Charles Daspit – LA DHH Roma Oliveri, Louis Trachtman, Charles DeGraw - OPH TB Control Eric Baumgartner - LPHI Lisa Longfellow, formerly of OPH Michelle Murtaza-Rossini, formerly of LSU Susan Bergson and Clayton Williams, formerly of LPHI

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Acknowledgements (3) Patient community LSU/TU clinicians ILH Infection Control Delta Region AETC LSU SPH Medical Informatics & Telemedicine LIS Core Group OPH nurses OPH epidemiologists OPH Disease Intervention Specialists OPH Medical Directors HCSD Programming Support LaPHIE workgroups membership

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Background (1) Epidemiology of HIV in Louisiana, U.S.A

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Background (2) Epidemiology of HIV in Louisiana, U.S.A In 2011 – Louisiana ranked 3 rd in US for estimated HIV case rates (30.2 per 100,000) – The Baton Rouge metropolitan area ranked 1 st (29.4 per 100,000) and the New Orleans metropolitan area ranked 4 th (25.3 per 100,000) in estimated AIDS case rates among the large metropolitan areas in the US – 32% of all persons living with HIV infection in Louisiana were not in care 2011 STD/HIV Program Report State of Louisiana, Department of Health and Hospitals, Office of Public Health

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Background (3) Missed opportunities for HIV care Louisiana State University (LSU) Health Care Services Division (HCSD) is an integrated delivery network (IDN) – 7 safety-net hospitals – Numerous ambulatory clinics – 70,000 inpatient admissions per year – 1.4 million outpatient encounters per year – Provides HIV treatment to 60–75% of HIV-infected persons in Louisiana 2007 data match identified 1,100 people with missed opportunities for HIV treatment and care

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Health information exchange (HIE) as a critical tool “…electronic movement of health-related information among organizations according to nationally recognized standards. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, timelier, efficient, effective, equitable, patient-centered care” 1 “…exchanging patient health information among health care providers regardless of the source of the information. HIE enhances patient care by providing timely access to more accurate and complete information” Strengthening Health Information Exchange

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Development of Louisiana Public Health Information Exchange (LaPHIE) LaPHIE – “No wrong door” approach at 8 hospitals and nearly 100 clinics – Real time identification of people out of HIV specialty care A programmatic, multi-organizational effort to improve health Advanced real-time health information exchange with EMR- integrated alerting system Capitalizes on opportunities to improve health outcomes – Opportunity to provide clinical services at time of alert – Allows re-engagement of patient in HIV specialty care and support services Designed to overcome system challenges Building system foundation – Qualitative work, legal analysis, community engagement, multiple organizational collaborations

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 System architecture Patient comes to clinic, hospital, or ED for non- HIV service Real time communication with surveillance system alerts physician that patient needs attention for HIV/AIDS Physician follows on- screen steps to re-engage patient into care and provide HIV treatment, as appropriate HIV clinic

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 OPH Firewall LSU Firewall ADT Registration Clinical Info. System Interface Engine LaPHIE Server PPR PRR ADT PPR / PRR Point-to-Point Dedicated T1 HIV/STD/TB Out of Care Patients

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 LaPHIE evaluation methods Research questionMethods Identification, engagement, retention, timeliness Cohort design Patient experience-Survey (quantitative) -Comparison of patients in care, at risk of being out of care, linked into care, proxies for high-risk patients out of care Provider experience-Survey (quantitative) -Qualitative interviews -Utilization data Feasibility, system impact, quality of care indicators, utilization -Qualitative interviews -Chronology and organizational assessment

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Impact (1) Between 2/1/09 and 7/31/ real-time alerts s hown to 223 clinicians – 58% physicians, 42% nurses or physician assistants 74% acted upon by clinician* Common actions taken at point of service** – 43% Referral to HIV care & treatment – 32% Discussing importance of treatment – 15% Assessing patient’s disease stage – 8% In care elsewhere or refused care *Of those not acted upon, 56% previously were addressed **Could be more than one

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Impact (2) Between 2/1/09 and 7/31/11 Identified 419 unduplicated HIV-infected persons out of care > 1 year – 24% no care since diagnosis – 76% at least one prior visit 55% of whom had been out of care ≥18 months Median time since last visit: 19.4 months [IQR 15.0– 32.5, range 0.20–108.7 months] 32% had not been seen in LSU system for any HIV-related test or care – Would have been missed in the absence of LaPHIE Note: Cumulatively between 2/1/09 and 12/31/12: 854 unduplicated, out of care > 1 year, HIV infected persons identified

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Impact (3) Characteristics of 419 individuals identified between 2/1/09 and 7/31/11 46% <35 years of age 68% black/African American 63% male Mode of HIV acquisition – 49% no identified risk or unknown – 22% heterosexual – 14% MSM – 4% IDU 42% CD4 < 200 cells/mm 3 – Median CD4 242 [IQR 75–407] 62% HIV RNA PCR > 10,000 copies/mL – HIV RNA PCR copies/mL 31,333 [2,762–147,327]

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Impact (4) Retention Of the 344 people identified in the first 18 months of the program and followed at least 6 months – 85% had at least one viral load and/or CD4 count Of those who had been out of care > 18 months before being identified – 82% returned for at least one visit Once identified by LaPHIE, patients were successfully retained in care – Majority of patients had at least one visit every 6 months – Declining viral loads in aggregate over follow up – Success in linking and retaining hardest to reach patients

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Impact (5) Retention

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Impact (6) Retention

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Case scenario Before and after LaPHIE BeforeAfter Repeat ER visits but no HIV care or treatmentNow linked into care Newly released from prison; post Hurricane Katrina evacuation; did not know where to go Linked by LaPHIE now in care “There will always be people falling through cracks” “Some people have given up” Opportunities to re-engage at least annually Denial, need to “come to terms with diagnosis”Immediate linkage: “It was very helpful that I was able to come in for my first visit on the next day after I called to make the appointment” Following Hurricane Katrina unaware that clinic had re-opened Appointment next day and given meds right then Structural barriers: no transportation, long work schedule, lost children’s social security cards, etc. LaPHIE alert helped link to services and then to care Frightened, denial, did not want to deal with diagnosis “Was given hope, I saw a graph that help me understand that my CD4 count could increase with treatment” Death of wife; slipped out of care due to depression Has come back for care as he has faced some of the struggles and has come out of it seeking care. He has set goals, met new people and is on path to excel in life and with HIV care

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 How can HIE support HIV-related outcomes? (1) An “EMR” is not enough HIV information exchange can promote – HIV prevention on the population level – Individual level health improvements Need systems that – Identify out of care persons with HIV – Link them into care and keeps them in care – Are not prohibitively expensive – Overcome distance and other characteristics – Acceptable to providers, patients, and communities – Confidential

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 How can HIE support HIV-related outcomes? (2) Using HIE with population-based approaches, Louisiana was able to – Identify out of care HIV-infected people – Facilitate engagement and retention in care – Engage them in HIV specialty care over follow up – Offer clinical services to improve individual- and population-level health Acceptable to patients and providers Well-developed, stakeholder involved process promotes success National interest and enthusiasm for HIE

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Questions For more information please contact Manya Magnus © Copyright 2009 Board of Supervisors of Louisiana State University and Agricultural and Mechanical College, through its LSU Health Sciences Center ALL RIGHTS RESERVED