Meaningful Use and Public Health: Rhode Island’s Perspective HIT Policy Committee Meaningful Use Workgroup Background Materials July 29, 2010 Amy Zimmerman, MPH Chief, Health IT Rhode Island Department of Health

Setting the Public Health Stage Meaningful Use Can Help To:  Transition from a sick care system to a well care system that proactively focuses on prevention  Apply core public health values to our health care delivery system by promoting population health  Eliminate the distinction between clinical data and public health data- it is the same data being used differently (at an individual level vs. at a population level)  Expand the traditional view of Public Health and allow providers to begin to serve as “agents for public health” by:  Engaging providers in population health for their practice  Transforming providers’ thinking to treating individuals as well as their patient population by implementing strategies that will help to improve the health of their patient population overall

Setting the Public Health Stage cont’d Meaningful Use Can Help To:  Promote the transfer of data to public health agencies to carry out traditional (core) public health functions in a more timely and efficient manner:  Supporting disease surveillance efforts through syndromic surveillance, disease reporting, registry reporting including immunizations  Inform, and shape public health messages by providing data that can be used for measuring outcomes and quality at multiple levels: individual patient, individual provider, practice and/or community/state level  Support public reporting – both of the use of HIT tools as well as the outcomes of care delivered

Meaningful Use and Public Health RI DOH Experience with EHR data/EHR type projects:  KIDSNET- integrated child health information system and immunization registry; Today would be considered a pediatric HIE (started in 1997)  Statewide HIE – pilot project to build initial phase of statewide HIE system to be operated and administered by state designated RHIO  Public Reporting: HIT survey that all licensed physicians are required to fill out (by law)  Capturing Influenza Like Illness (ILI) data through EHRs for H1N1- assessed potential to use EHRs to capture ILI during summer of 2009  Using prescription data to monitor H1N1 Outbreak- with 100% of retail pharmacies able to accept e-prescriptions, used medication data as additional surveillance tool  Flood Surveillance working with HCCN- worked with Health Centers to monitor health impact of March 31 st Flood  Laboratory ordering and results delivery- in place in limited fashion; working to expand  Syndromic surveillance – electronically in place with 9 of 11 hospitals

Meaningful Use and Public Health KIDSNET:  Functions as a pediatric preventive HIE; run by DOH  Data warehouse that provides an integrated record for all children born 1997 or after (for 9 child health programs):  Vital records, newborn developmental screening, newborn heelstick screening, newborn hearing screening, lead testing, immunization registry, early intervention, home visiting, and WIC  Has a clinical viewer for providers to access results  Provides quality reporting/feedback reports (on immunizations and/or lead screenings). Allows providers to monitor rates for their patient population and develop systems to ensure their patients get preventive services according to evidence-based guidelines and recommended schedules  Care coordination - Compares birth records with newborn screening tests; a missing newborn screen will trigger immediate program follow-up with hospitals and PCP, data used for continuous quality improvement

Meaningful Use and Public Health KIDSNET:  Used for data analysis to identified under-served populations; helps to target outreach at an individual and community level  Identified providers not using current standards of care  Allows state to monitor vaccine usage: Vaccine ordering is incorporated into KIDSNET which allows the state to monitor vaccine ordering and tie it to usage- especially helpful when there is a vaccine shortage and or targeting of vaccine such as with H1N1  KIDSNET Goals:  Expand to include lifelong immunization registry  Link to statewide HIE  Add heights and weights to calculate BMI and use for surveillance (obesity)

Meaningful Use and Public Health Statewide HIE:  State and regional demonstration project, funded by AHRQ to build initial phase of statewide HIE system (known as currentcare)  Applied on behalf of the community, always planned to transfer operations and management of HIE from state government to state designated RHIO (which is the Rhode Island Quality Institute)  Approach was to create a longitudinal health record for individuals regardless of where care was administered  Model was using a clinical viewer to access integrated view of patients’ data, with eventual plans to promote bidirectional data flow between providers EHRs and the statewide HIE  Not operational yet, will be starting with laboratory results and medication history data  Heavily engaged consumers and stakeholders. Resulted in “opt-in” consent process and an HIE system state law  Department of Health role changed over time. DOH now has regulatory responsibility  Increase in EHR adoption and MU has led to concerns around how to support and enhance this HIE model and competing efforts to meet meaningful use and aggregate EHR data (that fall outside of the law)

Meaningful Use and Public Health Public Reporting:  Public reporting law-passed in 1998; Requires public release of information about the quality of care in all licensed healthcare facilities  Includes information about patient satisfaction, clinical performance, etc.  Expanded to physicians in 2006 by requiring them to report on their use of HIT by annually filling out the state’s “Physician HIT Survey”  5 HIT measures in the survey: has an EHR; has a “qualified EHR” (RI definition of necessary functionality prior to meaningful use); uses an EHR; uses of advanced functionality of EHR; and e-prescribes  Physicians are required by law to fill out survey annually; if not reported, provider is listed as not having and HER; individual provider data listed on DOH website  Working with Medicaid and REC to determine how to leverage survey and to assist with Meaningful Use implementation; add questions, etc.

Meaningful Use and Public Health Capturing ILI through EHR for H1N1:  Assessed the ability to capture Influenza Like Illness (ILI) from dominant EHRs in RI (summer of 2009)  Not feasible to do so in needed time frame: Variations existed in the captured ILI data (text vs structured, location in record, multiple fields to enter the data in, etc.):  Between EHRs  Between the same EHR in different practices (different versions and different implementations)  Between the same EHRs in the same practice (differences in how physicians documented ILI)  EHRs that relied on structured data would have been able to report  While flexibility is needed to allow providers to adopt, this needed to be balanced with ability to capture data as structured data elements to support evolving public health and population health needs

Meaningful Use and Public Health Using Prescription data during H1N1 Outbreak:  Partnered with Surescripts and pharmacies to obtain regular updates of aggregate prescription data to use for disease surveillance (monitoring and tracking the use of antiviral data during the H1N1 pandemic)  Allowed DOH to:  Used the data as a proxy for H1N1 outbreak and compared data to the state's "Sentinel" system (of 25 physician practices around the state which report flu outbreaks)  Use of antivirals tracked well with surveillance of HINI outbreak  When ILI was being seen but it was not due to H1N1, allowed DOH to educate providers; this resulted in a corresponding drop in use of Tamiflu®  Identified that 5 percent of all Tamiflu® prescriptions were filled after 5 days from when it was written (too late); as a result DOH engaged in physician and patient education to reduce that gap  RI is the first state to have 100% of retail pharmacies capable of accepting e-prescriptions

Meaningful Use and Public Health Flood Surveillance:  Worked with Health Center Controlled Network’s EHR to obtain data to monitor health impact of major RI flood (March 2010)  HCNN EHR only captures structured data; enhances the ability to obtain requested data  Looking for increase in visits for asthma and GI illness  Requested and Obtained de-identified data on all encounters ( not just asthma GI) from 3 health centers over a set period of time that covered pre and post flood  Large volume of data made it difficult to easily manipulate and analyze data in a timely manner with the available tools at DOH  Very quick high level analysis did not indicate increase in asthma visits; nor attribute GI visits to flood  DOH epidemiologists gained experience working with EHR data  Need to consider using sampling strategies when abstracting and using EHR or HIE data due to potential volume of data set; lengthy unique ID codes etc.

Meaningful Use and Public Health Laboratory Ordering and Results Delivery:  State Health laboratory has implemented bidirectional ordering and resulting of laboratory test information for pertussis culture, PCR testing and influenza testing at the largest IDN (3 hospitals)  Working on expanding electronic exchange of test ordering and resulting to cover all tests and at all RI hospitals  Building an interface for electronic order and resulting to the Department of Correction’s EHR (mostly HIV and other STD tests)  DOH laboratory is considering the ability to pilot the NHIN Direct to provide connectivity between the hospitals and health centers to the State Health Laboratory

Meaningful Use and Public Health Syndromic Surveillance:  Rhode Island implemented the Real-time Outbreak and Disease Surveillance (RODS) system in 2006  Based on real-time chief complaint data from hospital emergency departments (ED); transmitted via HL7 messaging and analyzed electronically  RI monitors seven different syndromes through this system including botulinic, constitutional, gastrointestinal, hemorrhagic, neurological, rash and respiratory  Nine of eleven acute care hospitals are currently participating  Meaningful Use may help incent other 2 hospitals to report

Challenges and Concerns  By default, meaningful use promotes point-to-point connections as a means to allow for the exchange of health information electronically  Point-to-point is not cost effective nor does it support the development of a longitudinal record across all providers of care  Point-to-point perpetuates health care organizations’ ability to compete on access to information (only connecting with those business partners they choose) which may not be in the best interest of the patient  Meaningful Use and point-to-point connections do not specifically promote the use of regional or statewide HIE networks  For public health to support Meaningful Use, there is the potential need to have to build and support many point-to-point connections; public health does not have the resources for this  Other solutions are needed: NHIN Direct, use of statewide or regional HIE networks, etc.  Statewide HIE system may have challenges supporting public health needs if the system has an “opt-in” approach to consent

DOH Meaningful Use Priorities For Future  Support meaningful use via expanding ability to electronically:  receive reportable diseases from providers/labs etc. and send to NEDSS  receive laboratory orders and send results  receive immunizations administered and return immunizations recorded in KIDSNET that are not in the providers EHR  Minimize point-to-point connections by using NHIN Direct, statewide HIE  Have meaningful use criteria support the need to participate in n state or local HIE system  Expand quality feedback/reporting and public reporting, potentially based on meaningful use criteria  KIDSNET:  Implement bidirectional flow between KIDSNET and the statewide HIE to allow one method of meeting meaningful use and to minimize point-to- point connections  Include heights and weights  Expand KIDSNET to a lifelong immunization registry  Leverage and expand Physician HIT survey to support meaningful use and migrate state definition of “qualified EHR" to a meaningful use definition for consistency