Monitoring, Investigating, and Empowering Public Health with EHRs

Monitoring, Investigating, and Empowering Public Health with EHRs
Public Health IT Monitoring, Investigating, and Empowering Public Health with EHRs This is Unit 7 of your course entitled “Public Health IT – Monitoring, investigating, and empowering public health with EHRs” This material (Comp13_Unit7) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC

Public Health IT Monitoring, Investigating, and Empowering with EHRs
Monitoring, Investigating, and Empowering with EHRs Learning Objectives Describe the role of public health in context of clinical care environment Identify and describe the following three essential public health services: Monitor Health Diagnosis and Investigate Inform, Educate, Empower At the conclusion of this unit, students should be able to summarize how the essential public health services can be improved through the use of EHRs in the context of the clinical care environment Combine with Slide 3 Specifically, students will be able to: 1) Describe the role of public health in the context of the clinical care environment. 2) Identify and describe the three essential public health services - monitoring health, diagnosis and investigation, and informing, educating, and empowering stakeholders. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring, Investigating, and Empowering with EHRs Learning Objectives Identify public health practice challenges in these service areas Identify opportunities for EHRs and HIEs to address these challenges in Syndromic surveillance Notifiable disease reporting Public health case investigation Describe challenges & limitations of EHRs to address these service areas 3) Identify public health practice challenges in these service areas. 4) Identify opportunities for EHRs and health information exchanges or HIEs to address these challenges in syndromic surveillance, notifiable disease reporting, and public health case investigation. 5) Describe challenges and limitations of EHRs to address these service areas. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Overview Define public health
Role of public health enabled Electronic Health Records (EHRs) & Health Information Exchange (HIE) Monitor Health Notifiable Disease Reporting Syndromic Surveillance Diagnosis and Investigate Inform, Educate, Empower In order to discuss the concept of Public Health enabled EHRs and role of Public Health in Health Information Exchange (HIE), we will briefly define public health and its main objectives. In Unit 1 an introduction to public health was outlined. Once defined, we will then focus in on a few of the specific objectives that public health practice involves, describe the current context of public health practice today, and then discuss ways to leverage EHRs and HIEs to augment or facilitate these objectives and tasks. Throughout this course and presentation it will be evident that public health in many ways relies upon other sources to support its core functions, and the overlap between clinical care delivery and the activities of public health will become readily apparent. This is mentioned because it highlights that “Public Health” enabled EHRs and HIEs not only entail how these systems can be leveraged to better support public health activities, but also as importantly, for the users on the other end (clinicians, etc), facilitating their own respective actions Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Overview Define public health
Role of public health enabled Electronic Health Records (EHRs) & Health Information Exchange (HIE) Monitor Health Notifiable Disease Reporting Syndromic Surveillance Diagnosis and Investigate Inform, Educate, Empower We will first review the definition of Public Health and its core principles. These principles and concepts were previously described in Unit 1-please refer for a detailed overview of public health through electronic health record use. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

10 Essential Services In 1994, a steering committee composed of stakeholders from Public Health Service Agencies (Center for Diseases Control, Health Resource and Service Administration, Office of Disease Prevention and Health Promotion, National Institute of Health, and others) and key National Public Health Organizations was convened to provide, define and describe what constitutes public health. This steering committee developed the “Public Health in America” statement – which defined the vision and mission for public health as well as how public health should be delivered and the contexts under which this delivery should occur. At its core, the practice of public health was defined by this Steering Committee as being composed of 10 Essential Services, as illustrated on this slide. These 10 Services fall under 3 primary categories, Assessment, Policy Development, and Assurance – as originally defined by the 1988 Institute of Medicine report The Future of Public Health. Much of the data public health uses to monitor health commonly originate from the delivery of clinical care – a classic example of this is communicable disease surveillance. This monitoring in turn, may result in important messaging back to providers based on the findings from this monitoring, and the potential need for action on the part of clinicians and patients. And as many public health campaigns are targeting at improving the health of individuals which result in improved population health, quite often, these campaigns and programs again often require the analysis of clinical data to measure the final outcomes. Examples of this may include the reduction in obesity within a community post-intervention, or the impact on cancer and other related morbidities from anti-smoking campaigns within jurisdictions. Health information technology, and EHRs in particular, hold great promise in facilitating many of these Essential Services – this is especially true with 1) Monitoring Health, 2) Diagnosing and Investigating Community Health Problems, 3) Informing/Educating/Empowering People about Health Issues, and 4) Evaluation of Health Services. During this course, you will learn about specific examples of how EHRs and HIT have been leveraged to improve performance and delivery of these Essential Services. As many new providers prepare to adopt and meaningfully use EHRs based on federal stimulus incentives, public health agencies have a great opportunity to leverage this to significantly improve performance in these areas. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Notifiable Disease Reporting
Overview Define public health Role of public health enabled Electronic Health Records (EHRs) & Health Information Exchange (HIE) Monitor Health Notifiable Disease Reporting Syndromic Surveillance Diagnosis and Investigate Inform, Educate, Empower We will now move on to describing the role for public health enabled Electronic Health Records (EHR) and Health Information Exchange as it relates to Monitoring Health. We will begin by examining Notifiable Disease Reporting. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring Health Monitoring Health is one of the Foundations for the practice of public health. Without an understanding of the population health problems that exist, one cannot reasonably or efficiently implement programs intended to improve those problems. One of the core public health services performed at all levels of government (local, state, federal) is communicable disease surveillance. Communicable disease surveillance is necessary to monitor the natural course of communicable illness in communities and to detect when significant changes occur that could signify an emerging disease outbreak, change in the epidemiology of these conditions, etc. The image on this slide is from the New York City Department of Health and Mental Hygiene, which defines all the conditions within New York City where providers are mandated to report new instances of these conditions to the health department. In some instances of monitoring health, surveillance and subsequent investigation can lead to identification of new diseases in a community. One good example of this is the investigation that led to the discovery of West Nile Virus in New York City. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring Health (cont.)
Provider reporting essential to monitoring communicable diseases Providers have access to rich clinical & demographic information Public Health Agencies rely on medical providers to report new cases of communicable disease, and in some jurisdictions, have further incorporated laboratories to report new instances of communicable disease. While laboratory mandated reporting has been helpful in improving the reporting of new communicable diseases, laboratories generally lack important clinical and demographic information that providers can typically only provide. This data is necessary to track whether proper treatment is being administered, as well enable detailed analysis to identify changes in the epidemiology of these conditions (eg, are certain age groups, gender, race/ethnicities being affected more than others, are there risk factors that may contribute to incidence, etc). The figure on this slide is one page from the New York City Department of Health and Mental Hygiene’s Universal Reporting Form, which can be used by providers to report new cases of communicable disease. The hyperlink on this slide is to the Centers for Disease Control and Prevention's website that outlines the list of nationally notifiable infections conditions. This website can be accessed at Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Barriers Lack of knowledge of reporting requirements Time constraints Provider reporting not optimal, despite legal mandate Form completion, etc Lack of knowledge Over 80 notifiable conditions Limited resources available in small practices Despite the importance of provider disease reporting, provider reporting has been noted to be suboptimal from many prior studies. This has been attributed to various factors, including lack of knowledge or reporting requirements, time constraints, etc. This is particularly exacerbated by the limited resources found within small practices, where there may be no dedicated infection control practitioner who can be made responsible for reporting these conditions. In small practices, staff members often serve in multiple roles, and thus may be unable to adequately dedicate their time or attention to this reporting. And while legal mandates have been instituted to ensure proper reporting, they have not made an impact on improving these rates. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring Health EHRs can support Identification of cases for reporting via CDS Diagnostic codes (ICD-9-CM; ICD-10-CM) Lab results (LOINC) Streamline reporting with pre-populated forms Microsoft clipart As providers increasingly adopt EHR systems, public health agencies have an opportunity to leverage these systems to improving the state of provider reporting. One area EHRs can be leveraged to improve is in the area of provider awareness. Systems can prompt or alert providers of the need to report conditions when pre-defined criteria are met consistent with a reportable condition. These criteria may include a mix of diagnosis codes (such as ICD-9-CM and ICD-10-CM), laboratory results, and symptoms. One of the gaps currently is that there are no nationally recognized lists of criteria to define reportable conditions for use in EHR systems. However, CSTE is leading efforts to develop such a list. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Pre-population Utilize EHRs to pre-populate reporting forms Allows providers to focus on remaining questions Identifies the required fields for reporting Reduces time required to complete form which is barrier to provider reporting Wu, W. (2010). EHRs cannot only improve provider awareness of reporting requirements, EHRs also can provide pre-populated reporting forms that reduce the burden of reporting. This is achieved by filling in key demographic data on the patient and provider that are included on communicable disease reports. EHRs commonly store this information in a structured manner. This enables the provider to focus on reporting associated clinical data and treatment information that typically cannot be readily abstracted from an EHR system. To streamline this process, public health agencies may also choose to work with EHR vendors to electronically format these reports and submit directly to them, rather than rely on manual submission via mail or fax. This can considerably improve the impact on provider workflow and may translate to improved compliance and reporting by providers. The Institute for Family Health, as part of a joint collaboration between the New York City Department of Health and Mental Hygiene, and Columbia University implemented a clinical decision support tool to facilitate provider reporting of communicable diseases. This system was implemented in May 2008, and through the first seven months of implementation, a number of alerts were generated on numerous patients. In the Institute for Family Health system, alerts were triggered to fire when the ICD-9 diagnosis of a reportable condition was entered into the Assessment section of an outpatient encounter. The alert was linked to a printable NYC DOHMH reporting form, as well as an attached order set where providers could document their intended action (options included: report to be filed, report previously filed). The response rate of these alerts varied greatly by condition and further work is planned to investigate whether this alerting system actually resulted in an increase in the number of case reports reported and received at the NYC DOHMH. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Syndromic Surveillance
Overview Define public health Role of public health enabled Electronic Health Records (EHRs) & Health Information Exchange (HIE) Monitor Health Notifiable Disease Reporting Syndromic Surveillance Diagnosis and Investigate Inform, Educate, Empower Public health agencies may also monitor health in other ways besides through notifiable disease reporting. Syndromic surveillance is another method that may be employed. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Track encounters meeting case definition Chief complaint Diagnosis Other data Report counts for trend analysis Changes in trends investigated Wu, W. (2010). Syndromic surveillance involves the use of pre-diagnostic data to identify syndromes consistent with communicable illness. Trends in these syndromes can be tracked over time and abnormal increases investigated as a means to potentially detect emerging disease outbreaks before they are detected through traditional methods (e.g., laboratory confirmed cases of disease). The image on this slide is an example of how syndromic surveillance compares with WHO viral isolate data during a recent influenza season. The red and black lines represent percentages of encounters due to influenza-like-illness over time, compared with the green and purple lines, which represent WHO isolate data for Influenza A and B respectively. The peaks in the syndromic systems matched well with the Influenza A isolate data. Traditional disease surveillance generally relies on laboratory confirmed cases, and the lag time between when patients first present with symptoms and when they are tested and subsequently confirmed can take several days. This gap in time could result in potential lost opportunities for public health to intervene to contain and control a communicable disease outbreak. One national example of syndromic surveillance that is employed by CDC is ILINet. This is a voluntary network of providers that track the total number of encounters and encounters meeting the influenza like illness case definition, all stratified by age. CDC receives information and performs tracking of influenza like illness nationally. Stratification of this data by age is important to determine if influenza like illness is particularly prominent in different age groups, perhaps denoting increased risk. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Current Challenges Impact on provider workflow Maintaining counts Preparing reporting forms Transmitting weekly Microsoft clipart The main challenge with maintaining a voluntary syndromic surveillance system is that provider workflow can be significantly impacted. Maintaining counts of total encounters, syndromic encounter counts, stratifying by age, preparing data onto report forms, and transmitting weekly can be challenging in a busy clinic environment. Particularly when this work is not well integrated into the clinical workflow itself. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

EHRs track encounters meeting case definition Chief complaint Diagnosis Other data Report counts for trend analysis EHRs can minimize the burden of performing syndromic surveillance by providers. EHRs can be automatically calculate totals of encounters by week, stratified by age, and with pre-programmed case definitions, can calculate and report totals for different syndromes of interest by week, stratified by age. These case definitions can be defined using chief complaint, diagnostic, and other available structured data in the EHR. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Sample Surveillance Report
The image on this slide show an example of percent (%) of visits related to influenza like illness (as defined by the CDC as chief complaint of cough or sore throat and fever) over the course of the fall 2008 in a network of outpatient clinics, compiled from outpatient EHR data. The blue line and green lines represent the % of visits related to influenza like illness over different time periods, and both show a general increasing trend as time progresses and influenza season begins. The green line represents a much shorter time period and as a result, shows much more variability compared with the blue line. The additional benefit of syndromic surveillance leveraging EHR systems is that the degree of granular information that can be measured and provided via automated queries far surpasses the degree of information one can reasonably expect from a voluntary network of providers needing to calculate this information by hand. One additional layer of information that is potentially valuable is measured temperature. Objective measured temperature is a valuable piece of information, and readily distinguishes from possible worried well presentations where patients are presenting with complaints of fever that have not been measured either at home or in the office. Wu, W. (2010). Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Diagnosis and Investigate
Overview Define public health Role of public health enabled Electronic Health Records (EHRs) & Health Information Exchange (HIE) Monitor Health Notifiable Disease Reporting Syndromic Surveillance Diagnosis and Investigate Inform, Educate, Empower After notifiable conditions are reported or abnormal clusters of illness are detected, public health agencies may need to further investigate and diagnose if there is a potential cause for further concern/action, or if the conditions reported represent natural disease activity. Gathering follow-up information can at times be challenging due to busy provider workloads and difficulty in coordinating times to speak or limited ability to go to offices for follow-up. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Diagnose and Investigate Health Issues
RHIOs are organizations that support information exchange Public health officials can access RHIO for disease case investigation purposes Data may include demographics, laboratory values, medications In instances where health departments receive notification of reportable diseases, they must initiate follow-up investigation on these cases to assess risk factors and record clinical and demographic information for further epidemiologic analysis and study. Health departments often contact providers directly to obtain this information. As providers increasingly adopt EHRs, one potential resource health departments may tap to gather this data is through Regional Health Information Organizations, or RHIOs. RHIOS are the organizations of health care facilities and other health care providers that have entered into a relationship that supports the exchange of health information between participating sites. They commonly provide health information exchange amongst participating facilities/providers, and could provide a means for local health departments to readily gather additional clinical and demographic data for patients across multiple providers/settings, thus providing a more comprehensive picture of a patient. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Bronx RHIO In New York City, the health department has been collaborating with Bronx RHIO to implement the use of a RHIO to enable and facilitate communicable disease case investigation. The Bronx RHIO is composed of numerous stakeholders as listed above. Disease investigation staff at the New York City Department of Health and Mental Hygiene are able to securely log into the Bronx RHIO and under the umbrella of public health case investigation are allowed to access patient records for individuals with reportable illnesses. New York City Department of Health and Mental Hygiene staff utilize the RHIO to collect the additional clinical, demographic and other data required in a communicable disease case investigation. Laboratory data may be of particular interest in case investigation and RHIOs enable investigation to review results across multiple settings. Treatment information can also be abstracted from a review of medications provided. 1.1 Table: Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Inform, Educate, Empower
Overview Define public health Role of public health enabled Electronic Health Records (EHRs) & Health Information Exchange (HIE) Monitor Health Notifiable Disease Reporting Syndromic Surveillance Diagnosis and Investigate Inform, Educate, Empower Based on the activities of monitoring health and diagnosis and investigation, another important public health activity is to convey information back to the community so that they can act accordingly. This information may include specific recommendations for action, or just raise the level of awareness of a particular issue. In either case, the information should enable those affected or potentially affected in the community to make more informed decisions regarding their health. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Translating PH Information
Public health officials receive data from numerous sources Notifiable disease reports Syndromic surveillance Environmental monitoring These data are monitored and analyzed for abnormalities and potential threats Alerts are then shared to notify healthcare providers and the public In the context of notifiable disease surveillance, syndromic surveillance, and subsequent public health investigation, as well as other public health surveillance responsibilities, such as environmental monitoring, in the event that increasing disease activity deviates outside of expected natural activity, it is imperative that public health agencies provide notification of what is occurring to the general community. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Examples of Need for Info Exchange
Disease outbreaks Medication or vaccine recalls Environmental hazards Improve access to essential public health services Public domain, (2010). Examples of the types of information that may be disseminated by public health agencies can vary widely. Disease outbreaks, medication or vaccine recalls, environmental hazards (such as high heat alerts/ozone alerts), as well as notification of public health services implemented in response to emerging conditions (e.g., opening of cooling centers for high heat days, vaccination clinics for Hepatitis A outbreaks, etc) are just a few examples. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Current State of Info Exchange
Health Alert Network (HAN) MMWR Peer-reviewed literature Mass media Problem: Information not integrated into clinical workflow E-coli alert. (2007). In order to disseminate these messages, public health agencies may rely on different methods, such as the Health Alert Network, publication in the Morbidity and Mortality Weekly Report, and other peer-review literature, and mass media messaging (TV, radio, internet). For providers in the medical community, the challenge in integrating this information is that it is generally not integrated into their clinical workflow. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Current State - Workflow
This slide demonstrates the current state of how providers integrate public health messaging into their clinical practice. The slide starts at step 1 by showing that health departments receive information from medical providers on communicable diseases and syndromic surveillance, and based on analysis, may detect abnormal activity representing a disease outbreak. This information is then sent out via the Health Alert Network (step 2). The provider then consumes this information. However, since this information is often consumed outside of the provider workflow (for example, it is read in the morning in the providers box, or viewed on a website), the provider must then be able to recall this information and apply it to the relevant encounters he or she will see in his or her practice. The challenge is when the temporal gap between message and application is large, and also when the details of the message are more complex. Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Integration of PH Information via EHRs
Delivery of PH information by EHRs supports the following: Information provided in the clinical workflow Information provided in a contextually relevant manner Collection of important patient history, ordering of essential diagnostic tests, & delivery of appropriate treatment via actionable order sets Public domain, (2010). As providers increasingly adopt EHRs, the role of public health enabled EHRs to help improve public health messaging to medical providers becomes apparent. EHRs are capable of delivering clinical decision support, or CDSS, to providers at the point of care. This decision support is intended to provide relevant and specific information to the right patient at the right time. By leveraging CDSS to deliver these types of public health messages, the current challenges in effective messaging of public health alerts and information are mitigated. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Measles Alert HAN alert issued for measles cluster 2/25/08 Institute for Family Health placed alert next day Alert triggers: CC of fever and rash Alert triggered – 198 pts Acknowledged – 4 pts (2%) Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). One specific example of the use of CDSS to deliver public health information is in an alert implemented at the Institute of Family Health for a cluster of measles cases detected in Brooklyn in February 2008. The alert informed providers on cases of measles that were identified in Brooklyn, and suspected to potentially be the result of ongoing transmission between non-immune persons in the city. The alert then instructed providers to have heightened awareness for measles in patients presenting with rash and fever. In addition it provided instructions on how to receive rapid diagnostic testing from the NYC Public Health Laboratory (as commercial testing would likely take several days to receive confirmation). The slide illustrates that the alert was triggered in 198 encounters, and that the alert was acknowledged by providers, and reviewed in detail in 4 encounters, which translated to 2% overall. The alerts were designed to trigger on chief complaints of Fever and Rash. This alert particularly highlights the value of incorporating alerts into EHRs, as confirmation of measles cases using commercial testing would result in delays that could result in lost opportunities to vaccinate susceptible contacts. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Legionella Advisory HAN advisory issued for increase in Legionella cases in Bronx 7/24/07 Institute for Family Health placed alert on 7/27/07 Alert triggers: CC of fever Cough Chest pain Chest congestion Cold symptoms (Parkchester location only) Alert triggered – 142 pts Acknowledged – 5 pts (4%) Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). This slide demonstrates another example of a CDSS alert created by the Institute for Family Health and configured on a Health Alert Network message distributed by the New York City Department of Health and Mental Hygiene about the increase in Legionnaire’s Disease within the Parkchester section of the Bronx, New York. The alert was designed to trigger in patients presenting with chief complaints consistent with respiratory illness (fever, cough, chest pain, chest congestion, cold symptoms) and was designed only to trigger within a clinic found within the geographic area where Legionnaire’s Disease was on the rise. The alert was triggered on 142 patient encounters, with the alert being acknowledged in 5 patients – 4% overall. No cases of Legionella were detected. One thing of interest that was noted was that providers ordered Legionella Urinary Antigen testing for two patients. This test had never been ordered by providers at the Institute for Family Health, and it is possible that the increased awareness for Legionnaire’s Disease due to this alert may have lead to the ordering of these tests. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

E. Coli Alert HAN alert issued for E. coli O157:H7 multistate outbreak 9/28/07 Institute for Family Health placed alert on 10/1/07 Alert triggers: CC of diarrhea or stomachache Diagnosis of gastroenteritis Diarrhea or bloody stool Alert triggered – 287 pts Acknowledged – 65 pts (23%) Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). This slide shows one last example of a CDSS alert created by the Institute for Family Health based on an outbreak associated with contaminated ground hamburger meat in The alert was triggered by a chief complaint of diarrhea or stomachache, or if the treating provider entered any one of three gastroenteritis variants, one of the four diarrhea variants or melena/bloody stool into the diagnosis section of the chart. The alert was triggered on 287 patients, and was acknowledged in 65 patients, 23% overall. For providers who acknowledged the alert, they were provided with a linked order set that included orders for a Shiga-toxin assay along with routine stool culture. What is also highlighted by this example is that the alert itself provided opportunity to guide appropriate treatment. Within the messaging section, providers were reminded that “The only current treatment of EHEC infection is supportive, with monitoring for the development of microangiopathic complications such as HUS. Antiperistaltic agents increase the risk of systemic complications. Antibiotic therapy has no established effect on the duration of acute diarrhea.” Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Testing Performed at Visits
This graph demonstrates some preliminary data on the effect the E.coli alerts had on testing for diarrheal illness. The week corresponding to the implementation of the CDSS alert (as marked by the red arrow) was associated with the greatest total increase in the number of tests ordered for the entire year. The number of diarrheal encounters as represented by the thin blue line was around a baseline level. This preliminary data is noteworthy as other survey data previously reported found that providers were less likely to order diagnostic testing on patients for diarrheal illness potentially associated with a communicable disease outbreak. 1.1 Table: Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Future State - Workflow
This slide illustrates how EHRs overall can change the way providers are informed of emerging public health issues. Rather than having to consume information outside of their clinical workflows and recall this information at a later time, EHRs can bring this information to the point of care, in a contextually relevant manner. Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Limitations Value added to clinical care Alert Fatigue Making decision supports transportable Standard vocabulary Logic models Order sets Making more specific PH guidelines Our recent experiences in implementing these alerts found the following limitations in utilizing this approach. First, implementing public health alerts into EHRs must provide significant value added to clinical care as the relative value of all alerts may decrease as providers encounter more and more alerts within their clinical workflow. The end result is potential alert fatigue where providers may no longer pay adequate heed to clinical decision support alerts due to inundation. Second, at present, there exists no ready means by which public health agencies can configure public health related decision support alerts that can be consumed and readily implemented by different EHR vendors. This limits scalability of this approach and the potential reach of the value these alerts can provide. Third, as demonstrated by the relatively low acknowledgment rate of these alerts, it is important that public health agencies carefully define the criteria the triggering criteria for these types of public health alerts. While the primary goal of issuing public health alerts is to raise general awareness of an existing public health issue, the potential untoward consequences of this approach through EHR delivery of these messages must be appreciated to ensure that the overall value of these alerts remains high while carefully balancing this with the valid concerns over alert fatigue. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring, Investigating, and Empowering with EHRs Summary
Public health practice incorporates three key areas: Monitoring health Investigating and diagnosing health problems Informing, Empowering, Educating the public in how to respond to these health problems PH practice often relies on clinical care to provide reporting & data necessary to monitor health & detect emerging problems While PH practice often experiences resource limitations, they are expected to do more with less PH enabled EHRs and HIE hold promise in facilitating PH practice as more clinical providers embrace these technologies In conclusion, amongst the many different essential services that comprise public health, three of these services particularly rely on strong linkages with the clinical community for both data provision and appropriate action. These three areas are monitoring health, investigation and diagnosis of health problems, and the informing and educating of appropriate response to these problems. As public health practice is generally resource limited, and as providers continue to have limited resources to commit to public health activities within their own clinical practices, identifying ways in which to support these activities through public health enabled EHRs and Health Information Exchanges will ensure that public health practice can leverage technology to improve and manage public health. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring, Investigating, and Empowering with EHRs References
Lurio J, Morrison FP, Pichardo M, Berg R, Buck MD, Wu W, Kitson K, Mostashari F, Calman N. Using electronic health record alerts to provide public health situational awareness to providers. J Am Med Inform Assoc Mar 1;17(2):217-9. Hripcsak G, Soulakis ND, Li L, Morrison FP, Lai AM, Friedman C, Calman NS, Mostashari F. Syndromic surveillance using ambulatory electronic health records. J Am Med Inform Assoc May-Jun;16(3): Lazarus R, Klompas M, Campion FX, McNabb SJ, Hou X, Daniel J, Haney G, DeMaria A, Lenert L, Platt R. Electronic Support for Public Health: validated case finding and reporting for notifiable diseases using electronic medical data. J Am Med Inform Assoc Jan-Feb;16(1):18-24. Shapiro JS. Evaluating public health uses of health information exchange. J Biomed Inform Dec;40(6 Suppl):S46-9. The future of public health. Ten Essential Services. (1988). Institute of Medicine report. Retrieved on October 1st, 2010 from No audio Images: Slide 6: The future of public health. Ten Essential Services. (1988). Institute of Medicine report. Retrieved on October 1st, 2010 from Slide 8: Retrieved October 1st, 2010 from Slide 9: Retrieved October 1st, 2010 from Slide 11: Retrieved October 1st, 2010 from Image is Microsoft office clip art. Slide 12: Wu, W. (2010). Personal image of EHR- pre-population reporting. Primary Care Information Center, New York Department of Health and Mental Hygiene. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring, Investigating, and Empowering with EHRs References
Images (cont.): Slide 14: Wu, W. (2010). Sample image of syndromic surveillance compares with WHO viral isolate data during a recent influenza season. Primary Care Information Center, New York Department of Health and Mental Hygienge. Slide 15: Retrieved October 1st, 2010 from Image is Microsoft office clip art. Slide 17: Wu, W. (2010). Sample surveillance report. Primary Care Information Center, New York Department of Health and Mental Hygienge. Slide 20: Wu, W. (2010). Personal image of Bronx RHIO . Primary Care Information Center, New York Department of Health and Mental Hygienge. Slide 23: Public domain images of cells, European landscape, and pills. Retrieved on October 2st, 2010 Slide 24: E-coli alert. (2007). New York City Department of Health and Mental Hygiene. Slide 25: Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). Using automated EHR alerts to improve physician reporting. PowerPoint Presentation-Slide 5 at the International Society for Disease Surveillance Annual Conference. Slide 26: Image of two computers sharing information exchange. Public domain image. Retrieved on October 2st, 2010 Slide 27, 28, 29 & 31: Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). Using automated EHR alerts to improve physician reporting. PowerPoint Presentation at the International Society for Disease Surveillance Annual Conference. No audio Charts, Tables, Figures 1.1 Table: Lurio, J., Morrison, F., Pichardo, M., Berg, R., et al. (2008). Using automated EHR alerts to improve physician reporting. PowerPoint Presentation-Slide 15 at the International Society for Disease Surveillance Annual Conference. Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Monitoring, Investigating, and Empowering with EHRs

Monitoring, Investigating, and Empowering Public Health with EHRs

Similar presentations

Presentation on theme: "Monitoring, Investigating, and Empowering Public Health with EHRs"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Monitoring, Investigating, and Empowering Public Health with EHRs

Similar presentations

Presentation on theme: "Monitoring, Investigating, and Empowering Public Health with EHRs"— Presentation transcript:

Similar presentations

About project

Feedback