Integrated Clinical Database CPT Joseph P. Edger & 1Lt S. Erin Elarton 26 November, 2003 The purpose of this presentation is to introduce and briefly explain the Integrated Clinical Database (ICDB).

Outline What is the Integrated Clinical Database (ICDB)? The History of ICDB ICDB Mission Statement ICDB Architecture Where is ICDB deployed? Why was ICDB created? How does ICDB improve overall healthcare delivery process easier? How is ICDB important to the organization? Where is it going in the future, the system, and the processes? What does a healthcare administrator need to know about ICDB to be successful? This briefing will answer the following questions about ICDB: What does the system do? What what it before? Where is it going in the future? Where is it going in the future, the system, and the processes? Who are the normal users of the ICDB? How does ICDB fit with the other MHS databases (how, when, & why)? What does a healthcare administrator need to know about ICDB to be successful? How is ICDB important to the organization? How does ICDB improve overall healthcare delivery to all stakeholders?

What is Integrated Clinical Database (ICDB)? Provides Clinical Information via internal Web access Simplifies Data Access Designed to Meet the clinical Needs of MTF Medical Personnel Total Clinical information at your fingertips in seconds Downloads CHCS and other Legacy data The ICDB was developed to address two very specific needs within the MHS community. The first, is to simplify access and enable sharing of the mountains of data available within CHCS, and the second is to assist MTF personnel in the completion of their day-to-day tasks. The ICDB provides clinical information via internal Web access. It simplifies data access and was designed to meet the clinical needs of MTF medical personnel. ICDB allows for total clinical information at your fingertips in seconds. ICDB downloads CHCS and other legacy data. The USAF collaborated with Science Applications International Corporation (SAIC) to develop a market wide strategy to advance the business process of physicians accessing patient data. As a high-technology research and engineering company, SAIC computer system specialists have integrated Military Health Systems (MHS) databases ensuring database compatibility with the MHS Composite Health Care System (CHCS). http://icdb.tricaresw.af.mil/default.htm

The History of ICDB 1994: Started as an AF Initiative at Wilford Hall Medical Center as a tool for enabling user-friendly adhoc reports for CHCS Providers, Nurses, and Support Staff Created the Functional Requirements for the ICDB Application 1999: Beta deployment to Walter Reed 2002: Air Force Medical Service approved ICDB for AF wide deployment 2002: DITSCAP process completed and C2 Accreditation awarded 2003: Certificate of Networthiness (CON) by the Air Force Communications Agency 2003: AFMS-wide deployment planned The ICDB started as an initiative of the Air Force Surgeon General's office, and has continued to enjoy the support and guidance of the AFSG throughout it's development and fielding. From the beginning, the ICDB project has been focused on meeting the needs of personnel in the field. To support that aim, Providers, Nurses, and Support Staff helped to create the initial Functional Requirements used for the software development. The following dates summarize significant milestones accomplished by the ICDB fielding office: 1994: Started as an AF Initiative at Wilford Hall Medical Center as a tool for enabling user-friendly adhoc reports for CHCS Providers, Nurses, and Support Staff Created the Functional Requirements for the ICDB Application 1999: Beta deployment to Walter Reed 2002: Air Force Medical Service approved ICDB for AF wide deployment 2002: DITSCAP process completed and C2 Accreditation awarded 2003: Certificate of Networthiness (CON) by the Air Force Communications Agency 2003: AFMS-wide deployment planned http://icdb.tricaresw.af.mil/default.htm

Official Mission Statement Integrate data from diverse clinical information systems into a single, uniform, open-architecture platform that facilitates the rapid development, prototyping, deployment and sharing of leading-edge tools that support local commanders and their staffs in meeting both their unique, MTF-specific missions and MHS strategic goals. The Official Mission Statement for the ICDB program offers a view into the originating ideas and concerns that led to the tool being developed and fielded. The goal of this program was the creation of a tool that enables clinical staff to accomplish their mission of better quality care, by simplifying access to the data they need on a daily basis. The mission of ICDB is to integrate data from diverse clinical information systems into a single,uniform, open-architecture platform that facilitates the rapid development, prototyping, deployment and sharing of leading-edge tools that support local commanders and their staffs in meeting both their unique, MTF-specific missions and MHS strategic goals. http://icdb.tricaresw.af.mil/default.htm

ICDB Architecture for the MTF ICDB provides a relational database and software on the MTF intranet allowing all MTF users to share information Security and Privacy are continuously addressed for HIPPA compliance Downloads data from CHCS and SADR (Standard Ambulatory Data Record) HL7 Messages provide real-time updates from CHCS Information entered via ICDB, e.g. 2766 information, is stored and available to all software that uses ICDB database Installers have loaded 3-5 years of historical CHCS + SADR data into ICDB. ICDB is designed around the existing CHCS hardware available at each MTF, where it actively mines the data within CHCS, formats it for processing, and places it on the local Intranet for use by ICDB applications. Any changes or updates within the ICDB software are stored within the ICDB for immediate sharing with all other ICDB applications. This approach offers the latest information to each and every user within the MTF. ICDB provides a relational database and software on the MTF intranet allowing all MTF users to share clinical information. Security and Privacy are continuously addressed for HIPPA compliance. ICDB downloads information from CHCS and SADR (Standard Ambulatory Data Record). HL7 Messages is the technical standard that provides real-time updates from CHCS. Information entered via ICDB is stored and available to all software that uses the ICDB database. Installers have loaded three to five years of historical CHCS and SADR data into ICDB. http://icdb.tricaresw.af.mil/default.htm

Architecture for Tertiary MTFs Tertiary MTFs usually support several MTFs with their CHCS server All MTFs serviced by the Tertiary CHCS will have access to the Oracle/ICDB associated with the Tertiary facility The Tertiary MTF approach differs from the individual MTF approach in it's scope and overall size. For example, if changes to information within ICDB are made by any supported facilities within the network, they all will have access to the latest data. This architecture helps to create an environment of information collaboration, simplifying support and daily activities. For example, ICDB allows providers access to their patients information regardless of where the patient has been seen throughout the region. For instance, a patient who is enrolled through the Walter Reed Healthcare System may be seen at Walter Reed Army Medical Center, Dewitt Army Community Hospital, or Kimbrough Army Community Hospital, all located within the National Capitol Region. http://icdb.tricaresw.af.mil/default.htm

This map shows the DoD facilities where ICDB currently exists and where potential sites will deploy ICDB. Note that most of the facilities are Air Force MTFs, a few Army MTFs, two Navy MTFs and even the United States Coast Guard Yard in Baltimore, Maryland. The AF has funded an AF wide deployment and reached almost all of its facilities. The Army, Navy, and Coast Guard continue to add sites as Commanders approve the system. http://icdb.tricaresw.af.mil/default.htm United States Coast Guard Yard, Balt., Md

Why was ICDB created? Support Primary Care Optimization Medical Team Concept Expands the roles of nurses and medical technicians Staff work closer to their selected patient population Assists providers with their efforts to improve clinical practice Primary Care Optimization is a new approach to healthcare that capitalizes upon a medical team concept. The goal of PCO is to vastly improve the efficiency, effectiveness and quality of care delivered through our primary care platform. The primary care management system expands the roles of nurses and medical technicians working closely with their select patient population. This refined, coordinated approach to medical care enhances delivery of healthcare services and convenience to our patients, while at the same time, assists providers with their efforts to improve and expand clinical practice. For patients, PCO means health care will be delivered not only by primary care providers, but by a team made up of nurses, medical technicians and health services managers all working together to provide health care. Each team will have a sense of ownership over their patients' health. An important strategy within PCO is to recapture care from the private sector so that all enrollees can benefit and also to better manage the total financial risk of our health care system. Efficiencies are gained by improving clinical business processes, by enhanced partnerships with civilian and other federal healthcare partners, by effectively utilizing support staff skills, and through robust information management that supports evidence-based health care decision-making. Critical to PCO success is Primary Care Manager by Name, which provides patients with continuity of care and allows providers and their teams to better manage their practice by knowing who their patients are. http://icdb.tricaresw.af.mil/default.htm

How does ICDB make the healthcare delivery process easier? Decreases the number of times you have to enter data Obtain a patient’s clinical history in seconds Direct access to CHCS when you want to write orders/get new appointment, etc. Allows easy identification of your panel members View, edit, and update your patients Electronic DD Form 2766 Simplifies the Management of patients with similar medical conditions Identify and Follow “high risk” patients in your panel Simplifies Peer Review/Chart Review Helps you meet AFSG Initiatives Clinical education tool for Residents How does ICDB actually help you to do your job better and faster? It streamlines your access to important patient and work data, and simplifies the completion of your daily tasks. The bottom line? ICDB allows the MHS users to interact with patient data in a more efficient, and easier manner, while allowing updated information to be shared immediately within the MTF. The ICDB enables physicians, nurses, and support staff to access patient data, regardless of their locale within a MTF region, using powerful relational queries and using web-based technology during patient visits. http://icdb.tricaresw.af.mil/default.htm

How is it important to the organization? Improve the Quality of Care of our enrolled population Increases patient involvement in their own care Improves clinical decision-making Coordinates care across clinics Enables proactive interventions by identifying unmet needs Expands the roles and responsibilities of support staff Provides feedback to Providers, Staff, and Hospital Commanders on the effectiveness of their interventions Assists the MTF in passing inspections and surveys Now let's take a look at the REAL Deliverables of ICDB. What is it that ICDB delivers in ways that can be measured? By streamlining processes, and coordinating MHS practices, the clinical Quality of Care increases across the board for all patients. ICDB has dramatically affected the effectiveness and efficiency of patient-provider interaction, a key and essential business process of health care delivery. Providers may now conduct patient visits having comprehensive patient medical history improving the overall quality of care and patient satisfaction by eliminating duplication of costly medical tests, and reducing patient appointments. http://icdb.tricaresw.af.mil/default.htm

Provider Portal Point and click obtains last 3-5 years of host CHCS individual patient medical history – IN SECONDS Panel membership one click away Diabetics easily identified Identifies patients “falling through the cracks” Simplifies Peer Review/Chart Review Promotes better coding Promotes clinical education Promotes research Data retrieval is easier, faster The ICDB provides unique advantages to providers that in turn benefit their patients. The ICDB Provider Portal was created as a point-of-service tool to enhance the provider-patient encounter. Providers designed the ICDB tools needed to enhance their encounter in terms of productivity, efficiency, and satisfaction. Displaying provider defined information in an “easy to view” format is just the first step to delivering information that empowers providers and their staffs. Providers may now conduct patient visits having comprehensive patient medical history improving the overall quality of care and patient satisfaction by eliminating duplication of costly medical tests, and reducing patient appointments. http://icdb.tricaresw.af.mil/default.htm

ICDB Provider Homepage Opens to Your Appointments Once you've logged into the ICDB application, the Provider homepage will be displayed. From here you can navigate directly to the main ICDB tasks, you can view your scheduled appointments, and you can see the current status of those patients that you're keeping track of. The appointment system can be viewed by that day, the week, or the entire month and provides direct access to patient records within CHCS. The patient tracking section of the homepage provides a visual list of the patients you're currently tracking within the MTF. It gives you a quick reference that lists the patient's current status, as well as the ability to link directly to the patient's record. This tracking section can be customized by the system administrator at the MTF level to better suit local MTF needs. The patient tracking section can be customized to include recent ER visits, recently admitted patients, patients seen in other clinics, frequently seen patients, and patients overdue for prevention.

Identifying Cohorts of Patients Visiting ER This screen allows providers to identify all of their patients that recently visited the ER. Providers can search for patients who have visited the ER by the provider’s name or team. Providers can also limit their search to a certain age, sex, or birth month. Another great option is providers can limit their search to a certain number of days. Notice the option listed at the bottom of the screen to display the patients in an excel file.

Identifying Cohorts Overdue for Preventive Services This screen allows providers to identify their patients who are overdue for preventive services. Providers can search for patients by the provider’s name or team. Providers can also limit their search to a certain age, sex, or birth month. Another great option is providers can limit their search to a certain overdue test like mammograms or FOBT. Notice the option listed at the bottom of the screen to display the patients in an excel file. Display in Excel File

Clinical Summary -- ONE SCREEN The critical summary screen is a powerful tools that identifies opportunities for clinical prevention and intervention. This screen allows providers to view the status on all patients enrolled in their team, not just their own patients. This tool is valuable because often times a patient may have to visit another provider within the clinic if their provider is unavailable. This tool speeds up the treatment process by providing data for decision-making. From this screen a provider can view his recent information on appointments, admissions, medication, radiology, laboratory results, and specific procedures.

Individual Patient Summary The individual patient summary screen allows providers to assess their patients individually. The provider can see when the patient has been seen in the clinic, rather or not they were admitted, any medications they are on and any lab or radiology tests they have received. The medications option allows providers to view the medications that their patients are currently taking. Click

Medical Links – Research at the Click of a Mouse ICBD offers numerous medical links that connect to the internet without leaving the database. This is a very valuable tool that is not currently available through CHCS. Takes you back to the ICDB Home Page

Lab Results Over Graphed Over Time Note: Latest Labs Show On Trend This screen allows providers to view their patients’ lab results graphically to determine certain trends.

Nurse/Technician Portal Improve personnel management & efficiencies Project clinic resource requirements Coordinate care across patient conditions, services, and settings – over time Assist in understanding unmet need Case Management Support meeting JCAHO requirements The ICDB Nursing/Technician Portal allows PCO Team Members to easily tailor and access data related to their specific daily processes– enabling them to become the “force multiplier” in DoD health care delivery. Developed by nurses and their support staff, the Nurse/Technician Portal Tools improve the timely and accurate delivery of the data needed to support patient care, assist their PCMs to understand the un- met needs of enrollees, and facilitates their MTF in meeting patient assessment requirements for JCAHO. http://icdb.tricaresw.af.mil/default.htm

The nurse portal provides the nurse staff with real time data to assist the staff in providing the highest quality of care to the patient. Having knowledge of the upcoming day’s clinical workload allows the nurse and support staff to pre-plan for the expected utilization. The ICDB user (nurse or support staff) may also sort the data by column heading, health care teams, health care clinics, specific primary care provider, or time of appointment to further classify information in preparation for patient workload. The “total” patient visibility provided by ICDB, allows nurses and support staff employees to effectively coordinate for appropriate manpower, supplies, and logistical support for the delivery of health care in the most efficient manner.

Drilling Down on High Risk Patients In Your “ICDB Team” Panel The nursing portal provides an “alert system”, alerting the staff to it’s empanelled (high-risk) patients diagnosed with diabetes, visited the Emergency Department, admitted to a medical treatment facility within the network, seen for an appointment, or overdue for a follow-up and/or prevention health care service. ICDB offers the nursing staff multiple options to view the empanelled patients by diabetes metrics and some demographic information such as birth month, age, sex, and last name. These features are useful when the health care staff want to focus on specific patients e.g., OB/GYN, Geriatrics, Pediatrics, Diabetics, etc.

DD 2766 The DD 2766 is your “Master Problem List”. You can access a patients Master Problem List by clicking the DD 2766 link under the heading of Summary on the left column of your screen. The will allow a care provider to view, edit, or enter data on the patient such as medication allergies, other allergies, chronic illnesses, medications prescribed, hospitalizations, surgeries, counseling, and any advance directives. Clicking the chronic illnesses link opens a detailed window that allows staff to update the patient problem list by selecting a diagnosis. The staff may update all of the linked areas as similarly done in the chronic illness window. The electronic version of the DD 2766 is critical to the healthcare business process because it speeds up record’s reviews and is critical in meeting JCAHO standards.

Over Due Prevention Alert DD 2766 – Page 2 Over Due Prevention Alert Page 2 of the DD 2766 (Adult Preventive and Chronic Care Flowsheet) provides a wide array of screening exams that may be used for all patients. You may access this page by clicking the Prevention link under the heading of Summary on the left column of the page. At the top of page 2, data fields for the patient’s family history is listed. The family history window provides data fields for both parents, grandparents, and siblings listing any medical ailments. Also on this screen, a red “X” will appear next to the screening exam if that exam is applicable to the patient and overdue. The healthcare staff may annotate any comments and dates associated with the screening exam. Another feature for the healthcare staff is that they can click on any of the hyperlinked screening exams to obtain the patients results from previous exams. Lastly, by clicking the pencil icon, staff may view the patients vitals for the respective exam.

WRHCS Outcomes Management Database Outcomes Scorecards Cardiovascular Congestive Heart Failure Chronic Obstructive Pulmonary Disease Diabetes Hepatitis C Women’s Health Childhood Asthma Walter Reed Health Care System (WRHCS) Outcomes Management Database is an example of a partnership with the ICDB Office that increases productivity, efficiency, and quality of care by combining technology and medicine at the point of care. WRHCS Outcomes Management Database is an excellent tool for tracking high-risk patients. The Outcomes Scorecard allows clinicians to ensure continuity of care for its patients. WRHCS’s partnership with ICDB strengthens their commitment to high quality patient care through the use of advanced technology. http://icdb.tricaresw.af.mil/default.htm

Where is ICDB going in the future? “I see HealtheForces, MedBase, and [Park City Solutions] merging into one corporate ICDB solution.” COL Mark A. Lyford, MS, USA Joint Medical Information Systems Program Executive Officer HEALTHeFORCES is a fusion of best practices and best technologies designed to provide better communication and automation at the point of care - from the foxhole to the Medical Center (WRAMC). This fusion of forces will provide members of the healthcare team with the tools necessary to deliver national level care at any point of care along the healthcare continuum. HEALTHeFORCES will provide our military beneficiaries with healthcare that meets the highest national standards by exploiting advances in technology, wellness, prevention, and disease outcomes management. MEDBASE was developed at BAMC To provide users the tools necessary to efficiently perform daily business practices across multiple echelons of care and report to commanders relevant medical intelligence as a product of the normal health care practice. The Automated Patient Notification Portal from Park City Solutions is an Integrated Clinical Database (ICDB) extender application initiated at Luke AFB that was designed to build on the many functions already available within ICDB. The automated system notifies patients via telephone when laboratory test and radiology procedure results are complete, allowing patients to call into the system at their convenience to retrieve results. The automated laboratory and radiology notification system will help streamline current notification processes, reduce operating expenses, increase provider and patient satisfaction, and improve the overall efficiency and quality of care. http://icdb.tricaresw.af.mil/default.htm

HEALTHeFORCES is now a fusion of best practices and best technologies designed to provide better communication and automation at the point of care - from the foxhole to the Medical Center. This fusion of forces will provide members of the healthcare team with the tools necessary to deliver national level care at any point of care along the healthcare continuum. HEALTHeFORCES will provide our military beneficiaries with healthcare that meets the highest national standards by exploiting advances in technology, wellness, prevention, and disease outcomes management. HealtheForces link: HealtheForces: http://www.healtheforces.org/default.htm HealtheForces Awards: - The Walter Reed Army Medical Center, Washington, D.C. has been selected as a finalist for the "The Grace Hopper, 2003 Government Technology Leadership Award"; in the award category of "Leadership in the innovative application of information technology that contributes to the advancement of scientific knowledge and its applications." - For the Walter Reed Army Medical Center, Washington, D.C., 2003 proves to be a winning year. The HEALTHeFORCES program has received awards and certifications from the Joint Commission on Accreditation of Health Care Organizations, and most recently The Emerging Technology and Healthcare Innovations Congress. - Walter Reed Army Medical Center (WRAMC) HEALTHeFORCES has achieved Disease-Specific Care Certification of Distinction for four of its disease management programs and two of its preventive health services for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Chronic Obstructive Pulmonary Disorder, Congestive Heart Failure, Pediatric Asthma, Diabetes, Cardiovascular Risk Reduction, and Women's Health.

What does a healthcare administrator need to know about ICDB? Helps move the organization to a proactive, prevention-based system Ensures patients do not “fall through the cracks” Enhances “point of care” processes Quality measurement and improvement Assists MTF’s in passing inspections and surveys ICDB builds an information infrastructure to deliver actionable information to support and enhance “point of care” processes, quality measurement and improvement, clinical and health services research, and clinical education. ICDB helps move the organization to a proactive, prevention-based system. It assures patients do not “fall through the cracks” and enhances “point of care” processes. ICDB is an effective quality measurement and improvement initiative that assists MTF’s in passing inspections and surveys http://icdb.tricaresw.af.mil/default.htm

ICDB Contact Information ICDB Program Office Office of the Air Force Surgeon General 5201 Leesburg Pike, Suite 1401, Skyline #3 Falls Church, Virginia 22041 ICDB Operations Office 7800 West IH-10 Suite 620 San Antonio, Texas 78230 210 292-8450   http://icdb.tricaresw.af.mil/default.htm Information is available at the ICDB homepage located at URL, http://icdb.tricaresw.af.mil/default.htm ICDB Program Offices are located in San Antonio and Falls Church, Virginia.

Summary ICDB enhances CHCS I by providing coordination of care across: Patient conditions Clinical services MTF settings ICDB is a valuable tool for healthcare providers. It enhances CHCS I by providing coordination of care across patient conditions, clinical services, and MTF settings. http://icdb.tricaresw.af.mil/default.htm