Implementation (An LHII supporting care, public health and research in Indianapolis ) Clem McDonald, M.D., FACP Marc Overhage, M.D., Ph.D., FACP Mike Barnes, M.D. Paul Dexter, M.D. NHII 2004 Cornerstones for Electronic Healthcare Washington, DC July 22, 2004 Regenstrief Institute 1050 Wishard Blvd, 5 th floor Indianapolis, IN 46202

2004 © Regenstrief Institute, Inc. It is more important to build the highway ….

2004 © Regenstrief Institute, Inc. Highway

2004 © Regenstrief Institute, Inc. … than the Hotel or Fast Food Place

2004 © Regenstrief Institute, Inc. The Local Health Information Infrastructure is the highway u It connects the health care players u It delivers clinical data in standardized form to the users u It provides the guard rails and protections for data riding on the highway

2004 © Regenstrief Institute, Inc. The office EMR is the hotel along the road u It accepts the clinical data from the LHII feeds u Provides special local services u But hotel is not the only choice – A camp ground (ASP web EMR) might suffice

2004 © Regenstrief Institute, Inc. The highway always comes first u You don’t build hotels and fast food restaurants and expect that a highway will show up u It is the other way around u Same with the LHII and medical record systems. Build the LHII first

2004 © Regenstrief Institute, Inc. Highway is key because so much electronic clinical data lives beyond the office u Commercial/referral laboratory results u Out side consultants notes u Hospital produced data (all kinds) 1. Operative notes 2. Pathology reports 3. Discharge summaries 4. Cardiology studies 5. Radiology reports 6. Tumor registry 7. More… u Prescription records (in pharmacy benefit management systems) u More..

2004 © Regenstrief Institute, Inc. INDIANAPOLIS NETWORK FOR PRIMARY CARE (INPC) u Up and running for more than 7 years u Began with one project – provide data from all hospitals for Emergency care u We Extended by adding public health, other practice/MD access mechanisms, and research--- a step at a time u Focus on Clinical, public health and research uses issues –- so far

2004 © Regenstrief Institute, Inc. Indianapolis Network for Patient Care (INPC) – a real living LHII 1) A central (community) clinical repository 2) A secure network for delivering clinical data messages to repository 3) Tools and processes for standardizing the data and using it for different purposes 4) Formal agreements among all participants spelling out processes and allowable uses and HIPAA compliance

2004 © Regenstrief Institute, Inc. Advantage of centralized repository for LHII u Standardizing happens centrally with concentrated expertise u Apply one effort to standardize each large data stream and many practices and uses cash in on the same effort u Can find and route public health data to public health u Assume one standardized output for office-based medical records u With central repository 1. The LHII can be the medical record 2. The LHII can also serve authorized research uses

2004 © Regenstrief Institute, Inc. Who contributes data u Five major Indianapolis hospital systems (14 hospitals) 95% of hospital and ER care u Three (so far) hospital associated group practices u Four homeless clinics u Public health departments Immunization records Immunization records Public health department lab results Public health department lab results Tumor registry (de-identified research only) Tumor registry (de-identified research only)

2004 © Regenstrief Institute, Inc. State Board of Health County Health Department Quest LabCorp

2004 © Regenstrief Institute, Inc. All hospitals contribute – at least u Discharge summaries/admissions summaries u Operative notes u Radiology reports u Pathology reports u Cardiology reports u Tumor registry data u 2/5 – so far -- contribute MUCH MORE u Public health contributes data too

2004 © Regenstrief Institute, Inc. How does the data flow from source to LHII repository – HL7 Messages delivers most of the clinical data. DICOM for radiology images NCPDP for outpatient pharmacy LOINC – Provides standard codes that defines the content of each delivered result.

2004 © Regenstrief Institute, Inc. Data flow to repository Data flow to repository clinical Message Map Code to LOINC Standardized Institutional Vault Institutional Source

2004 © Regenstrief Institute, Inc. Storage & Message Volumes – 06/04 # HL7 message streams 84 ( 2 DICOM streams, 1 NCPD # HL7 messages per year 52 million # observation rows total 489 million # new observations/per yr 81 million 81 million # text (dictated) reports total 12 million 12 million # CPOE orders stored (wish) 24 million 24 million # EKG tracings stored 480 thousand # Radiology images total 45 million ( 2 systems) 45 million ( 2 systems) # Radiology images new/yr 25 million ( 2 systems) 25 million ( 2 systems) Document image pointers/yr 13 million ( 1 system) 13 million ( 1 system)

2004 © Regenstrief Institute, Inc. Don’t make it more complicated u HL7 vs. 2.X works just fine u Problems all come from flagrant dis- regard of the HL7 Specs e.g: u Coded data sent without codes or coding system –(Just text) u Units put in value field instead of units field u Technical improvements can’t fix this

2004 © Regenstrief Institute, Inc. Limits u Only have outpatient prescriptions for about 20% of the city- Working with RX Hub to get much more u Many large practices still to add

2004 © Regenstrief Institute, Inc. Who uses u Clinicians u For ER patients in any of 14 emergency rooms. (expanding to much larger group) u Patients in institutions where clinicians have admission privileges ( virtual record ) u Patients with reports related to clinician. Unified electronic report delivery (200 office sites (30% of city) so far Scheduled to include most of city by end of 2005 u Public health u reportable diseases u Immunizations u bioterrorism u Researchers – Pyloric stenosis

2004 © Regenstrief Institute, Inc. Provides a Health Information Infrastructure * u Broad capabilities for clinical care u Research (cancer biology and epidemiology u Public Health * Report and Recommendations from the National Committee on Vital and Health Statistics. Information for Health: A Strategy for Building the National Health Information Infrastructure. Washington, DC, November 15, 2001.

2004 © Regenstrief Institute, Inc. INPC Storage Strategy u Central Community repository - ESSENTIAL u Separate medical record vault per institution u Each vault in separate physical files u Standardized data structure – All use same software and observation codes. u Combine on the fly when needed u Patient linking

2004 © Regenstrief Institute, Inc. INPC database organization St. Vincent’s Community Hospitals Wishard Clarian Health Global Patient Index Dictionary MCHD Global Doctor File Reportable Conditions St. Francis LabCorp

2004 © Regenstrief Institute, Inc. INPC and ER Care u Patient checks into ER u HL7 message to INPC Computers u Computer delivers précis of key ER data printed in Index ER u Provides ER MD’s look-up access to all INPC content for 24 hours

2004 © Regenstrief Institute, Inc. Emergency Dept. Data Flows Emergency Department INPC Registration Message Merged Clinical Abstract Merged Result Retrieval ED Charge Data

2004 © Regenstrief Institute, Inc. INPC Data Access

2004 © Regenstrief Institute, Inc. How it looks from the web u Merged patient views u Browser based u How data from “another” institution are footnoted on screen and printed output u Access logs

2004 © Regenstrief Institute, Inc. Flow sheet for blood count

2004 © Regenstrief Institute, Inc.

Radiology Images - Thumbnail

2004 © Regenstrief Institute, Inc. BIG

2004 © Regenstrief Institute, Inc. BIGGER

2004 © Regenstrief Institute, Inc. BIGGEST 2800 x 2000

2004 © Regenstrief Institute, Inc.

Report delivered to office practices

2004 © Regenstrief Institute, Inc. Report delivery to office practices u 200+ practices (1000 MDs) at present u Scheduled for whole city by end of 2005

2004 © Regenstrief Institute, Inc.

INPC’s Public Health Goal Link clinical activities and public health activities to improve the population’s health (Pluck reportable cases from H L7 streams )

2004 © Regenstrief Institute, Inc. To Infection Control To Infection Control Reportable condition processor InboundHL7InboundHL7 Potentially Reportable Potentially Reportable Condition Reportable Condition To Public Health To Public Health Reportable Conditions Databases Reportable Conditions Databases Abnormal flag, Organism name in Dwyer II, or Value above threshold Compare to Dwyer Table I content (LOINC codes) Record Count as denominator Summar y Realtime Daily Batch Print Reports

2004 © Regenstrief Institute, Inc. Sample notification

2004 © Regenstrief Institute, Inc. Security/Confidentiality u Agent of SBOH under MOU u Private network (moving to VPN) u Encrypted file transfer u Controlled database access Location linked IP address Location linked IP address User name/password User name/password

2004 © Regenstrief Institute, Inc. Reportable disease example

2004 © Regenstrief Institute, Inc. Shigella Outbreak: Geography

2004 © Regenstrief Institute, Inc. John Snow & the Broad Street Pump

2004 © Regenstrief Institute, Inc. Outcomes u Reliable u Real time delivery u 100%received (for participants) u Reporting completeness (capture/recapture) u Greatly increased case reporting u Reporting timeliness (versus result date) u 8.4±15.4 days faster than HD u 1.4±2.0 days faster than hospital

2004 © Regenstrief Institute, Inc. Related activities u Prompt physicians to screen u Immunization Registry u Syndromic surveillance ED chief compliant ED chief compliant u “Push” to infection control

2004 © Regenstrief Institute, Inc. De-Identified Research u SPIN project u NCI funded Collaboration among IU/Regenstrief Harvard, U of Pittsburgh UCLA u De-identified cancer research u Main aim is to provide access to pathology reports and paraffin blocks via searches on full medical record.

2004 © Regenstrief Institute, Inc. Challenges of Distributed De-Identified Data u Definition of de-identified (in flux) u Scrub data of identifiers u Translate identifiers to unique keys u Link de-identified data via these keys

2004 © Regenstrief Institute, Inc. Specify Cohort

2004 © Regenstrief Institute, Inc. Specify statistical breakdowns

2004 © Regenstrief Institute, Inc. One way to show output as breakdowns

2004 © Regenstrief Institute, Inc. As we solve the user authentication problem, opportunities are vast u All providers could have EMR at miniscule cost u Unmatched database for clinical research that could improve population base u Pervasive options for feedback and reminders to MD

2004 © Regenstrief Institute, Inc. Acknowledgement Support from u National Library of Medicine u National Cancer Institute u Regenstrief Foundation u Lilly INGEN grant

2004 © Regenstrief Institute, Inc.