BIRTH, DEATH AND THE
ELECTRONIC HEALTH
RECORD
SETH FOLDY, MD MPH
SETHFOLDY.COM LLC PREVENTIVE HEALTH
SYSTEMS
BIG QUESTIONS
1. Will Electronic Health Records (EHR) be an
important source of Electronic Birth and/or Death
Record Systems data?
2. Should the process of data exchange be partially
or completely automated?
3. When and how should the VR community position
itself?
4. How should the VR community prepare?
QUESTION 1:
• Will Electronic Health Records
(EHR) be an important source
of Electronic Birth and/or
Death Record Systems data?
MEDICARE/MEDICAID ELECTRONIC HEALTH
RECORDS (EHR) INCENTIVE PROGRAM
(‘MEANINGFUL USE’)
• $27B Medicare/Medicaid incentive program (EHR
Incentive Program, or ‘Meaningful Use’) is driving
EHR adoption
• 2009 ARRA HITECH Act
• Eligible hospitals and professionals
• Financial incentives turn into Medicare penalties
after 2016
• National certification requirements for EHRs
• Objectives of “meaningful use” of EHR
EHR USE TRENDING UPWARD, PACE
QUICKENING
Percentage of office-based physicians with EMR/EHR systems: United
States, 2001–2010 and preliminary 2011–2012
CDC/NCHS, National Ambulatory Medical Care Survey, 2001–2012.
February 2013 – By the Numbers
FEBRUARY – BY THE NUMBERS
Registered Eligible
Professionals
527,200 Total EPs
22.76%
50.13%
27.11%
Registered
Medicare EPs
(264,292)
Registered
Medicaid EPs
(120,002)
6
February 2013– By the Numbers
FEBRUARY – BY THE NUMBERS
Paid Eligible Professionals
15.03%
26.54%
2.11%
527,200 Total EPs
56.32%
Medicare EPs
(139,910)
Medicaid EPs
(79,257)
MAO EPs (11,117)
7
February 2013– By the Numbers
FEBRUARY – BY THE NUMBERS
Registered Eligible
Hospitals
14.21%
85.79%
5,011 Total Hospitals
Registered Hospitals
8
February 2013– By the Numbers
FEBRUARY – BY THE NUMBERS
Paid Eligible Hospitals
24.55%
75.45%
5,011 Total Hospitals
Hospitals Paid
9
WHO DECIDES?
• Office of the National Coordinator for HIT (HHS, Dr.
Farzad Mostashari)
• Advises HHS Secretary on information standards
• HIT Policy and Standards Committees are Federal Advisory
Committees (FACA)
• Establishes EHR certification requirements
• Supports Health Information Exchange (HIE: moving data
from one party to another)
• Supports privacy and security
• Supports research, evaluation, innovation
WHAT DOES THIS MEAN FOR VR AND
PH COMMUNITIES?
• EHR Systems certified to national standards
• Meaningful Use incentives already require some of:
•
•
•
•
Electronic lab reportable results to public health (hospitals)
Syndromic surveillance
Immunization Information System reporting
Cancer Registry Reporting
• Has created pressure on public health systems
• Increasing standardized data flow to PH
BEYOND THE TIPPING POINT?
• 2013 survey (Accenture) 93% of U.S. doctors reported using
EHR systems.
• More than in France; Singapore; Australia; England; and
Canada.
• 78% of U.S. physicians routinely enter notes into EHRs;
• 65% of U.S. physicians routinely prescribe drugs electronically;
• 62% of U.S. physicians receive clinical results in their EHR system,
a 24% increase from the prior year;
• 57% of U.S. physicians use electronic laboratory orders, a 21%
increase from the prior year;
• 45% of U.S. physicians use health information exchange
technology to access clinical data from outside their
organization, a 32% increase from the prior year; and
• 38% of U.S. physicians say that using EHRs and HIEs has lowered
their organization's costs (Healthcare IT News, 5/9).
http://www.ihealthbeat.org/articles/2013/5/10/survey-says-more-than-90-of-us-physicians-now-use-ehrs.aspx#ixzz2UPAfHeO4
BEYOND THE TIPPING POINT?
• Most health trade groups advocating to continue
Meaningful Use incentive program
• Many calling for
• Slower pace (delay Stage 3)
• Fewer requirements (relax Stage 2, or less specificity in Stage
3)
• AM News: “Many physicians view electronic health
record use like their patients might think of exercise.
They don’t necessarily enjoy it while they are doing
it, but they recognize and appreciate the benefits.”
NAPHSIS: VR AND THE EHR
• Approximately 99% of all births and 35-40% of
deaths in the U.S. occur in hospitals.
• Approximately 50% of Birth and Fetal Death data
elements are derived from the medical record.
WILL ELECTRONIC HEALTH RECORDS (EHR)
BE AN IMPORTANT SOURCE OF ELECTRONIC
VITAL RECORD SYSTEMS (EVRS) DATA?
• YES: EHR replacing paper records
• YES: some data reported to VR systems will first be
recorded in EHRs as
• Structured data (pick-lists, translated, computable)
• Unstructured data (text)
• Data quality in EHR compared to paper records will:
 Increase
 Remain same
 Worsen
• Data will be transferred to VR systems
• Manually?
• Automatically?
• A combination?
• The Question: does the VR community desire that
• EHRs be certified to standardized collection/reporting of some
EVRS data elements?
• Providers incentivized to report some data electronically to EVRS?
ISSUES FOR VR
• Will data be structured in EHR as needed for VR?
• Will EHR support additional data entry for VR?
• Will EHR data systems support data quality checks
for VR?
• Will EHR support needed accountability for VR
reporters?
• Will the process support providers’ and VRs’ business
needs?
QUESTION 2:
•Should the process of
data exchange be
partially or completely
automated?
GOALS FOR IHE PROFILE PROJECT
• Establish interoperable electronic exchange of VR data
between EHR and VR Systems
• More timely data release
• Higher quality data for demographic and epidemiologic
surveillance and research
• Less costly electronic vital registration systems
• Greater integration with other stakeholder electronic systems
• Greater standardization of electronic VR data collection and
exchange
Michelle Williamson. IHE Quality, Research & Public Health Agenda 8/27/12
http://www.ihe.net/Events/upload/2012-08-24_QRPH_PublicHealth_Focus_IHE_Webinar.pdf
WHY AUTOMATE ANYTHING?
• Improve consistency
• Increase speed
• Reduce costs
Or
• Better
• Faster
• Cheaper
STATE REGISTRAR/NCHS/PH
PERSPECTIVE
• BETTER?
•
•
•
•
Data received more accurate/appropriate/precise?
Data received more complete?
Data elements meet processing requirements?
DEPEND ON ADEQUACY OF EHR CERTIFICATION
•
•
•
•
•
•
Delivered to EVRS faster?
Registration accomplished faster?
Transmitted to NCHS faster?
Certificates available to individuals faster?
Statistics and tools (e.g. death index) available for use faster?
DEPEND ON PROVIDER BEHAVIOR, EVRS SYSTEM CAPABILITY
•
•
•
•
•
Less labor per record?
Less labor for follow-ups?
Simplified workflow for record completion?
EVRS cheaper to produce, procure, maintain, replace?
DEPEND ON EVRS SYSTEMS LEVERAGING EHR STANDARDS
• FASTER
• CHEAPER
CLINICAL PERSPECTIVE
(INCL. FUNERAL DIRECTOR)
• BETTER
• Data for quality, safety, & cost management?
• Reimbursement or incentives?
• Patient satisfaction (effort, access to certificates)?
• FASTER
• Completion of each registration?
• CHEAPER
•
•
•
•
Less labor per initial record?
Less labor for follow-ups?
Workflow for completion?
EHR cheaper to produce, procure, maintain, replace?
HOW IMPORTANT IS THE CLINICAL
PERSPECTIVE?
• ACA: growing price/performance pressure on
hospitals and physicians
• If it doesn’t decrease cost, increase income or
improve clinical quality, who cares?
• Would Registrars or hospitals win a legislative power
show-down in your state/territory?
TENTATIVE CONCLUSION
• IF certified EHRs capture well-defined data elements
using standardized vocabulary, and
• IF EHRs present said data for validation,
supplementation, and certification by the health care
provider, and
• IF this occurs timely in a clinical-friendly workflow, and
• IF EVRS systems build toward ONE clear standard for
receiving and processing this data,
• THEN semi-automated EHR reporting could be better,
faster AND cheaper for both clinicians and VR offices
QUESTION 3
• When and how should the VR
community position itself?
“Need for a long-term, shared strategy for
achieving the vision of interoperable vital
records systems with electronic health
record systems.” Denton Atkinson, NAPHSIS 2012 mtg
IN FACT, YOUR LONG TERM PLAN IS
ABOUT TO INTERCEPT STAGE 3
MEANINGFUL USE OPPORTUNITY
?
2012-13
HL7 messages &
IHE profile
2009-11
VR Domain Analysis Model
EHR-S VR Functional
Profile
2007
2003
MoVERS
IS IT TIME?
To achieve consensus on standards…
…and advocate they be adopted for Stage 3
Meaningful Use…
…and force EHR technology to be certified to the
standards…
…and prepare to accept electronic transmission?
IN YOUR FAVOR:
• Slow-down in selection (& maybe deadlines) of
Stage 3 Meaningful Use objectives
• ONC Standardization and Interoperability
Framework activities:
• Harmonization of VR data elements with other public health
reporting activities in the Public Health Reporting Initiative
• Positioned to lead in the Structured Data Capture (SDC)
Initiative
DOUG FRIDSMA1: ONC SDC INITIATIVE
Initiative’s goal is to identify, evaluate and harmonize four new standards
that will enable EHRs to capture and store structured data:
1.
Standard for the structure of the common data elements that will be
used to fill the specified forms or templates.
1.
Standard for the structure or design of the form or template (container)
that common data elements can sit in.
1.
Standard for how EHRs interact with the form or template.
1.
Standard to auto-populate form or template
Focus on research, safety event, and public health reports.
May closely adhere to VR work in the Quality, Research and Public Health
(QRPH) committee of IHE.
1Director
of Standards & Interoperability, ONC
WHY FOCUS ON SDC INITIATIVE?
• If successful, will likely be given priority in future
Meaningful Use stages
• If successful process, will be supported by research,
safety and public health communities
• May be “imposed on” public health community
THREE LAYERS OF EXCHANGE
STANDARDS
Healthcare
Provider
Vital Records
Secure Transport
(PHIN-MS, DIRECT, WebServices)
Data Exchange Format
(HL7 message, C-CDA document)
Content/Vocabulary
(LOINC, SNOMED)
BUSINESS 2 BUSINESS (B2B)
Healthcare
Provider
Vital Records
HIE ORGANIZATION MODEL
Healthcare
Provider
Vital Records
HIE
Organization
PUBLIC HEALTH HUB MODEL
Healthcare
Provider
Vital Records
PH Agency
Hub
NEED TO CONSIDER POSSIBLE TRADEOFFS
• Balanced scorecard
•
•
•
•
•
Data quality
Speed
Convenience, Labor & Cost
Accountability
Pace of Change
WHAT LIKELY WON’T WORK FOR
MEANINGFUL USE (OR ANY NATIONAL
STANDARDIZATION)
• Forcing data providers/EHRs in different states to
use different formats, e.g.,
• Clinical Document Architecture in one state
• HL7 2.5.1 messaging in another
• Major differences in reporting requirements
between states/territories
• Failing to establish some uniform expectations of
VRDS vendors
POSSIBLE STRATEGY
• Advocate for an acceptable set of SDC standards for
birth and/or(?) death records
• Seek inclusion in Stage 3 Meaningful Use EHR
certification requirements
• Consider if VR reporting should be incentivized for
hospitals and/or eligible professionals in Stage 3
Meaningful Use
• If Stage 3 does not contain VR certification requirements,
consider other options for certifying EHRs
• Consider certifying EVRS’ to
• manage standardized EHR data
• acceptable workflows for VR staff
QUESTION 4
•How should the VR
community
prepare?
DRIVE TOWARD INFORMED CONSENSUS:
1. CAPABILITY
1.
2.
Establish national strategic/tactical leadership
•
•
•
•
Trusted federal, state, and territorial leaders
Contributing to national FACAs and other committees
On-going communication with VR programs
Able to make decisions rapidly with appropriate consultation
Designee in each VR program to
Become familiar with core documents:
•
•
•
•
•
•
•
•
•
•
EHR-S VR Functional Model
VR Domain Analysis Model
VR HL7 message guides and document architecture
IHE profile
Track and comment on SDC Initiative products
Follow pilot test process and evaluations
Educate leadership and staff
Establish connections with PH department Meaningful Use lead,
State HIT Coordinator
Support participation in national decision making as needed
DRIVE TOWARD INFORMED
CONSENSUS
2. LEARNING
• Community examination/discussion of pilot projects
• Regular discussion of SDC Initiative process
• What are necessary and viable trade-offs in
•
•
•
•
•
Data quality
Speed
Convenience, Labor & Cost
Accountability
Pace of Change
DRIVE TOWARD INFORMED
CONSENSUS
3. DECISIONS
• Birth reporting, death reporting, or both as “first
mover” for EHR reporting?
• Based on readiness, practicality and desirability
• Preferred format (2.5.1, CDA) for receiving EHR
information?
• In consultation with EHR and EVRS vendors
• Are SDC products acceptable and actionable?
• May require compromise with other stakeholders (research,
safety reporting, other public health programs)
• Should SDC VR products be adopted for national
use?
DRIVE TOWARD INFORMED
CONSENSUS
3. DECISIONS (CONT.)
• Should SDC or other standards be included in
“Meaningful Use” EHR certification in Stage 3 (2016
or 17)?
• Should VR reporting be added to Meaningful Use
Stage 3 incentive objectives (2016 or 17)?
• Will numerous VR programs be ready to receive during
Stage 3?
• Should VR reporting use a nationally-uniform system
of secure transport?
• DIRECT? SOAP? PHIN-MS? Other? Or variable?
DRIVE TOWARD INFORMED
CONSENSUS
4. ADVOCACY
• If green light: advocate for VR standards adoption
into Meaningful Use certification
• If green light: advocate for VR reporting as a
Meaningful Use incentive objective
• If green light: advocate for a national standard for
secure transport of VR records
DRIVE TOWARD INFORMED
CONSENSUS
5. IMPLEMENTATION
• Initiate discussions with state/territorial PH Meaningful
Use leader and State HIT Coordinator regarding:
• HIE or Public Health hub management of transport/receiving
reports
• Ensure EVRS vendors begin adopting national
standards
• Consider certification
• Work with EVRS vendors on workflow redesign for
maximum benefit from EHR data
• Consider certification
• Prepare for on-boarding EHR data providers
• Prepare to exploit improved data management
capabilities
CONCLUSION
• Opportunity exists—window length?
• Assessment and decisions needed
• Requires
•
•
•
•
Capacity (national leadership, local liaisons)
Participation
Learning
Decisions
• Trade-offs
• Advocacy
• Implementation
• Payoff depends on EVRS and workflow re-design