Course: Introduction to Public Health InformaticsLecture 2: Electronic Health Records and Public Health
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Content
Electronic Health Records
EHRs and Public Health Systems
SPH 210 - 2010
Overview
The role of EHRs in public health Re-thinking public health in an electronic healthcare world Augmenting public health with health IT
± Regional bed capacity planning and management ± Disaster planning and management ± Vital records and EHRs
Public Health and HIE
Role of EHRs in Public Health
EHRs not typically considered a tool for enhancing public health Do they have a role?
± automating reportable disease data collection ± acquiring data in structured, computable form ± monitoring disease patterns
syndromic surveillance hospital admissions discharge data
± quality improvement is a public health issue
Re-thinking Public Health
Public health has traditionally been constrained by the paper-based nature of healthcare data EHRs and HIEs dramatically alter the information landscape and provide unprecedented opportunities for public health What should the role of public health departments be now that EHRs and HIEs carry significant amounts of health data in computable electronic form?
What is the NHIN?
~ 2005 the ONC proposed a framework for national data exchange ± the National Health Information Network (NHIN) 2010 ± NHIN is operating as the ³NHIN Limited Production Exchange´
± connects federal agencies and private organizations to exchange health information ± SSA, MedVirginia, VA, DoD, Kaiser Permanente
NHIN CONNECT
NHIN Connect is open source software designed to support health information exchange at an enterprise level Originally developed by federal government to support exchange among a select set of federal agencies
± over 20 federal agencies involved
DHHS, AHRQ, CDC, CMS, FDA, HRSA, IHS, NIH, DoD, DOE, EPA, DOT, VA, NASA, etc..
NHIN Connect Architecture
Three primary components
± Core Services Gateway
provides ability to locate patients at other organizations request documents associated with a patient mechanisms to evaluate authorizations for release of medical information
± Enterprise Service Components
set of key enterprise services needed to support exchange
master patient index, Document registry and repository, Authorization policy engine, Consumer preferences manager, Audit log
± Universal Client Framework
set of applications that can be adapted quickly to use NHIN Connects gateway
NHIN Connect Capabilites (v2.3)
NHIN Connect v2.3 ± released Jan 2010 Content
± HITSP C.32 Summary of Care document ± CARE Profile ± GIPSE Profile
Services
± ± ± ± ± ± ± ±
±
Patient Discovery Document Query Document Retrieval Consent Management Audit Logging Health Information Event Messaging Authorized Case Follow-Up Document Submission\
http://developer.connectopensource.org/display/NHINR231/NHIN+Specification+References
A link to the NHIN Connect specifications:
NHIN Security
NHIN nodes must authenticate each other and encrypt information exchanged between them Accomplished using public key infrastructure (PKI) to create secure channels between NHIN nodes using standard Internet Transport Layer Security (TLS)
NHIN Architecture Overvidew, v1.0. Jan 29, 2010
NHIN Messaging
NHIN¶s common transport layer
± messaging standards ± web service protocols
NHIN Patient Discovery
The initiating node sends a patient discovery request to one or more patient discovery web service end points for target NHIN nodes Each responding NHIN node attempts to match the set of demographics provided with those in its own master person index If a single match, the responding node sends the Patient Identifier (PID). If a single match is not achieved, the target may respond with an error condition which may either request additional attributes or indicate a match cannot be achieved. The initiating node can take resulting PIDs and perform subsequent patient-specific transactions with the remote NHIN node that has asserted a match for this person
NHIN Architecture Overview, v1.0. Jan 29, 2010
NHIN Query and Retrieval of Documents
Query for Documents allows an NHIN node to request a patient-specific list of available documents from a remote node Subject to an authorization decision, the responding node returns a list of document identifiers and other metadata associated with the documents The Retrieve Documents services retrieves one or more of the documents using the Document Identifier
NHIN Architecture Overview, v1.0. Jan 29, 2010
NHIN Health Information Event Messaging
Allows an initiating NHIN node to establish a subscription to information held by a responding node for periodic exchange
± subscription: node sends a sub request to responding node. The receiving node grants the request to establish the subscription ± notification: the responding NHIN node notifies the subscriber as events occur which match the approved subscription criteria
NHIN Architecture Overview, v1.0. Jan 29, 2010
NHIN Document Submission
Allows an initiating node to send one or more documents for a given patient to a receiving node without a prior query/retrieve request The receiving NHIN node may evaluate the documents submitted and accept or reject them, and return an Accept or Reject status to the originating node
NHIN Architecture Overview, v1.0. Jan 29, 2010
What is CARE?
Continuity Assessment Record and Evaluation (CARE) Part of the CARE Health Information Exchange Project (C-HIEP) a data set being developed by CMS to promote data exchange in support of improving the quality of care for patients as they transition among providers Major Domains for CARE data set
± ± ± ± ± ± ± Administrative Medical, Health Status Cognitive, Mood, Pain Impairment Functional status Plan of Care Discharge, caregiver needs
What is GPSIE?
GIPSE ± Geocoded Interoperable Population Summary Exchange GIPSE is a data format created by the CDC to allow electronic exchange of health condition summary data stratified by a number of variables, including geography ± to support biosurveillance GIPSE¶s data element descriptions GeoLocation and GeoRegion information
NHIN Architecture Overvidew, v1.0. Jan 29, 2010
Virtual Lifetime Electronic Record (VLER)
Aug 13, 2009 - President Barack Obama, Defense Secretary Robert M. Gates, and Veterans Affairs Secretary Eric Shinseki, announced the VA and the Defense Department were creating a joint virtual lifetime electronic record, or VLER. VLER is a federally funded initiative to exchange health information to provide a lifetime medical record for service members. Goal - to help prevent misplaced paperwork and help providers maintain and offer quality health care for service members A useful test case for NHIN Connect
http://fcw.com/Articles/2010/02/04/Defense-Veterans-VLER-Virtual-Lifetime-Electronic-Record.aspx?p=1
Examples of Public Health Functions improved by EHR adoption
Bed capacity Disaster planning Disaster management Improves statutorily mandated monitoring
± infectious disease ± lead levels ± cancer
Improve vital record reporting
Public Health Advantages of HIE
Improved timeliness of reportable diseases Opportunity to identify gaps in preventive health Geographic visualization of illness or injury Real-time display of temporal and geographic disease related data on a dashboard
Health Informatics and Public Health
Mandated reporting of laboratory diagnoses Mandated reporting of physician diagnoses Public health investigation Antibiotic resistance surveillance Population level quality monitoring
Shapiro. Evaluating public health uses of health information exchange. Journal of Biomedical Informatics 40 (2007) S46 S49
State Health Information Exchange Cooperative Agreement Program
A program funded by HI-TECH (ARRA) Managed by ONC Goal:
± to develop and advance mechanisms for information sharing across the health care system
Provides $564 million to support ³efforts to achieve widespread and sustainable health information exchange within and among states...´
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1333&parentname=CommunityPage&parentid=47&mode=2&in_hi_userid=11113&cached=true#
State HIE Cooperative Agreements
If funded, a state must:
± develop and implement privacy and security requirements for HIE ± develop directories and technical services to enable interoperability within and across states ± coordinate with Medicaid and state public health programs to enable information exchange ± remove barriers that may hinder effective HIE
interoperability across labs, hospitals, practices, health plans and others.
± ensure an effective model for HIE governance and accountability is in place ± convene health care stakeholders to build trust and support for a statewide approach to HIE