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P660 - Special Topics in Physical Therapy

• Explain the forces in the current healthcare
environment promoting adoption of information
Medical Informatics • Appreciate the types of problems in clinical
practice and healthcare delivery that may be
amenable to improvement with more judicial use
09.28.2006 of information technology.
• Describe the broad areas of intellectual focus
within the field of biomedical informatics, in
Dr. Daniel J. Vreeman, PT particular, clinical informatics.
• Identify the challenges in integrating and
exchanging electronic information between
• Discuss key factors for success in developing the
Indiana Network for Patient Care.

References Session Overview

Required Readings: • Forces in healthcare driving information
• Vreeman DJ. Clinical prediction rules. Phys Ther. 2006;86(5):761-762.
• Lobach DF. Clinical informatics: supporting the use of evidence in technology adoption
practice and relevance to physical therapy education. Journal of
Physical Therapy Education. 2004;18(3):24-34. • Clinical Informatics
• Vreeman DJ, Taggard SL, Rhine MD, Worrell TW. Evidence for electronic
health records in physical therapy. Phys Ther. 2006;86(3):434-449. – As an academic discipline
• Biondich PG Grannis SJ. The Indiana Network for Patient Care: an – Applications
integrated clinical information system informed by over thirty years of
experience. J Public Health Manag Pract. 2004;Suppl:S81-86. – National Trends in Health Information
Technology (HIT)
Optional Readings:
• McDonald CJ. Protocol-based computer reminders, the quality of • INPC Case Study
care, and the non-perfectability of man. NEJM. 1976;295(24):1351-1355.
• Tierney WM, McDonald CJ. Practice databases and their uses in • Applications to Physical Therapy
clinical research. Stat Med. 1991;10(4):541-557. – EHRs in PT
– Informatics competencies for all healthcare

What is Medical Informatics?

• Informatics
– The science that studies the use and processing of data,
information, and knowledge*

Biomedical Informatics
The rapidly developing scientific field that deals with
Forces in Healthcare Driving
resources, devices, and formalized methods for
optimizing the storage, retrieval, and management of
Adoption of Information
biomedical information for problem solving and decision
making** Technology
• Medical Informatics
– Improving healthcare with information technology
• Bioinformatics
– Proteomics, etc

* van Bemmel JH, Musen MA (eds). Handbook of Medical Informatics. Heidelberg: Spinger-Verlag. 1997.
** Greenes RA, Shortliffe EH. Medical informatics. An emerging academic discipline and institutional priority. JAMA. 1999;263:1114-1120

A Patient Scenario from the ED A Patient Scenario from the ED
A pt comes to the ED with crushing chest pain. MDs at this ED have access to a computerized
He was very ill and unable to provide a patient record, aggregated from all the EDs in
medical history. Indy.
The physicians were concerned about his chest The EHR data showed that this pt had been
treated at a nearby hospital for a head injury
pain and thought he may be having a heart just 3 weeks prior.
Giving anticoagulants would have increased
Standard treatment for this is to give bleeding in his brain, forcing an unnecessary
anticoagulants, to return blood flow back to head surgery and an injury that easily could
the injured area. have killed him.

Clinical Decision Making Clinical Decision Making

What’s the Problem?

• Making sound clinical decisions requires: • Man is an imperfect data processor

– Right information, right time, right format – We are sensitive to the quantity and organization
• Clinicians face a surplus of information of information
– ambiguous, incomplete, or poorly organized – Army officers and pilots commit ‘fatal errors’ when
given too many, too few, or poorly organized data
• Rising tide of information – The same is true for clinicians who ‘watch’ for
– Expanding knowledge sources events
• 40K new biomedical articles per month
– Clinicians are particularly susceptible to errors of
• New tests, genomic data, etc
– Improved communication methods
• Internet [WWW, email, TCP/IP]

• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.

• Tierney WM. Improving clinical decisions and outcomes with information: a review. Int J Med Inf. 2001;62:1-9. • Tierney WM, McDonald CJ, Martin DK et al. Computerized display of past test results – Effect on outpatient testing. Ann Int Med. 1987;107(4) 569-574.

Clinical Decision Making Clinical Decision Making

What’s the Problem? What’s the Problem?

• Humans are “non-perfectable” data • What data?

processors – Physical therapists make decisions by considering a variety
of patient and environmental factors
– Better performance requires more time to process – Expanded practice roles of physical therapists
– Irony • Increased diversity and autonomy
• Clinicians increasingly face productivity expectations • Where does that data live?
– Facilities where PTs work with established productivity – Somewhere else or you collect it (again)
• Paper versus electronic
» 1999 – 47.2%
• Isolated systems
» 2002 – 62.5%
• Clinicians face increasing administrative tasks • Patient information is often missing (13.7%) at the time
of a clinical visit

• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.
• Lopopolo RB. Hospital restructuring and the changing nature of the physical therapist’s role. Phys Ther. 1999;79(2) 171-185. • Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83(3):224-236.

• American Physical Therapy Association. Reported Productivity Expectations of PTs 1999-2002. Available from http://apta.org • Smith PC, Araya-Guerra R, Bublitz C et al. Missing clinical information during primary care visits. JAMA. 2005;293(5):565-571.

Types of Data That May Be Generated From a Patient/Client History
General Demographics Medical/Surgical History Current Condition/Chief Complaint
Clinical Decision Making



Concerns that led the patient/client to seek the
services of a PT
Concerns or needs of patient/client who requires the
How Can Computers Help?
• Race/Ethnicity • Gastrointestinal
services of a PT
• Primary Language • Genitourinary
• Current therapeutic intervention(s)
• Education •

• Mechanisms of injury or disease, including date of
onset and course of events
• Eliminating the logistic problems of the paper record
Social History • Onset and pattern of symptoms
• Musculoskeletal
• Cultural believes and behaviors
• Neuromuscular • Patient/client, family, significant other, and caregiver

Family/Caregiver resources
Social interactions, activities, and support systems
• Obstetrical
expectations and goals for the therapeutic
intervention 1. Simultaneous, remote access to patient data
• Prior hospitalizations, surgeries, and pre-
• Patient/client, family, significant other, and caregiver
Employment/Work existing medical and health conditions
perceptions of patient/client emotional response to
2. Legibility of record
• Psychological the current clinical situation
• Current and prior work, community, and leisure
actions, tasks, or activities • Pulmonary • Previous occurrence of chief complaint

Growth and Development • Prior therapeutic intervention(s)

3. Data failure protection
• Developmental history
Functional Status / Activity Level
• Hand dominance
• Current and prior functional status in self-care and 4. Data security
Living Environment home management, including ADLs and IADLs

Devices and equipment
Living environment and community characteristics
• Current and prior functional status in work,
community, and leisure actions, tasks, or activities 5. Flexible data layout
• Projected discharge desirations
General Health Status • Medications for current condition
6. Integrated information from multiple sources
• General health perceptions • Medications previously taken for current condition
• Physical function • Medications for other conditions 7. Enhanced search capabilities
• Psychological function

Role function
Social function
Other Clinical Tests 8. Enhanced output capabilities
• Laboratory and diagnostic tests
Social/Health Habits
• Behavioral health risks

Review of available records
Review of other clinical findings
9. Real-time access to information
• Level of physical fitness

Family History Revised from American Physical Therapy

Association. Guide to Physical Therapist Practice 2nd
• Familial health risks Edition. Phys Ther. 2001;81(1)S1-752
• Powsner SM, Wyatt JC, Wright P. Opportunities for and challenges of computerization. Lancet. 1998; 352:1617-1622.

Clinical Decision Making Clinical Prediction Rules in Action

How Can Computers Help?
Clinical Prediction Rule for Diagnosing Deep Vein Thrombosis (DVT)
• Vreeman DJ. Clinical prediction rules. Score Clinical Finding Pat/PT Exists?
Phys Ther. 2006;86(5):761-762. 1 Active cancer (ongoing tx, w/in previous 6 mo, or palliative)

– Computers are tireless data processors 1 Paralysis, paresis, or recent plaster immobilization of the LE’s
1 Recently bedridden for >3 d or major surgery w/in 4 wk
– Computerized reminders informed by
1 Localized tenderness along distribution of the deep venous
electronic data can improve care system

outcomes 1 Entire LE swelling

• Convincingly demonstrated in medical 1 Calf swelling > 3 cm when compared with asymptomatic LE

literature 1 Pitting edema (greater in symptomatic LE)

1 Collateral superficial veins (nonvaricose)
• Reminders have not been studied in PT settings
-2 Alternative dx as likely or greater than that of proximal DVT

Probability: 0=low, 1-2=moderate, ≥ 3=high

Childs JD, Cleland JA. Development and Application of Clinical Predictions Rules to Improve Decision Making in Physical Therapist Practice. Phys Ther. 2006;86(1):122-131.

Clinical Decision Making Considerations for Good Reminders

How Can Computers Help? Reminders work best when…

• Group Activity: • Making a decision is based on explicit criteria

– Bad: “If the pt doesn’t improve…”
– Examples from physical therapist practice – Good: “If the pt’s SBP is above 180…”
• The criteria can be assessed with data available
• The reminder is patient and problem specific, not
– Bad: “Maternal depression is an common problem…”
– Good: “Jenny’s parent identified symptoms of depressed
• The reminder system is integrated into natural work flow
– Timing, logical presentation, shows rationale, links to more info
• Clinicians generally accept the action as best practice

Consumerism Consumerism
How Can Computers Help?
• Empowered patients with changing expectations
• Integrate information from multiple sources across
the life-span, but with challenges:
• Technology-enabled experiences
– Care and information are fragmented [reconciliation]
– Rapid, multi-modal communication
• Explosion of health information available on the WWW
– Large portions of record are not captured electronically
– E-commerce – Issues of identity, security, privacy, and trust
– Online banking • Consumers view computerization as ‘state-of-the-art’
• Consumers (patients) are demanding – Can promote a perception of high quality
– Speed • Repositories can be the information source for
– Convenience customizing healthcare delivery and resource
– Customized service and tools distribution
• Patient and condition-specific • Computers/repositories can enable process and
– Security, confidentiality system integration to improve the consumer
– Customer Relationship Management solutions
– Online scheduling, tracking, communication, etc…
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.

Expanded Uses of Health Information Expanded Uses of Health Information

• JCAHO • Public Health

– Requires organizations to collect data to support
• Managerial operations
– Reportable conditions
• Performance improvement activities – Reporting requirements (which vary) are
• Patient care mandated by state laws
• HIPAA (Transactions Rule + Privacy Rule + Security Rule + Proposed Claims Attachment Rule) • Research
– Administrative procedures
– Physical safeguards
– Clinical data repositories have well
– Technical security services
documented research uses
– Mechanisms to ensure privacy and security – Examples: clinical epidemiology, patient risk
NEW! – Standards for electronic claims attachments assessment, post-market drug surveillance,
• Message + data standards practice variation, resource consumption,
• X12, HL7, and LOINC® quality assurance, and clinical decision making

• Tierney WM, McDonald CJ. Practice databases and their uses in clinical research. Stat Med. 1991;10(4):541-557.

Expanded Uses of Health Information

How Can Computers Help? Cost of Care
• Potential efficiencies gained via improved data • US invests $1.7 trillion annually
– Storage
– Retrieval – 16% of GDP
– Processing and analysis • 2x the EU average
– Transmission
• Serious problems with
– Monitoring and tracking (quality assurance)
• Enhanced, explicit security mechanisms – Inefficiency
– Poor quality
– Lack of access

Cost of Care EBP and Quality of Care
How Can Computers Help?

• Estimates of saving $140 billion annually “The conscientious, explicit, and judicious
• How? use of current best evidence in making
– Improved information sharing decisions about the care of individual
– Improved care coordination patients. The practice of EBM means
– Reduced redundancy integrating individual clinical expertise
– Reduced medical errors with the best available external
• The challenge remains that mere evidence from systematic research.”
adoption won’t produce savings
• Real process change (transformation)
must occur
Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings and costs. Health Affairs. 2005;24(5):1103-1117.
* Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(13):71-72

Why all the Hype? Quality of Care

• Justification “Indeed, between the health care we now
have, and the health care we could
– The cost-conscious healthcare have, lies not just a gap, but a chasm.”
– Care that is effective and efficient State of U.S. Health Care:
– Professional responsibility – Complex care is typically uncoordinated
and information is not available to those
who need it, at the time they need it
– Patients often don’t get the care they
need, or they get care they don’t need.

• Institute of Medicine. Crossing the quality chasm: A new health system from the 21st century. Washington, DC, National Academy Press 2001.

EBM and Quality of Care EBM: Physical Therapist’s View

How can computers help?

• Efficient access to needed clinical • Generally positive view of EBP

information • Interested in increasing skills and amount of
• Efficient access to primary literature
• Reported use of databases to search literature
• Tools to support implementing the best was related to computer access
evidence at the point of care – Home > Work
• Facilitate measurement, monitoring based – Practice setting-dependant

on clinical details, not just claims data • Lack of time was the greatest reported barrier

• Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(13):71-72
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
• Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.

Barriers to EBP PT’s Literature Access and Availability

• Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.

Why Informatics?
• All of these forces
– Clinical decision making
– Consumerism
– Expanded uses of health information
– Quality of care
are converging on the need to effectively The Field of Medical Informatics
manage health information
• Inadequacy of our current paper-based
health information system

Informatics is the field that has arisen to address

(through scientific study) the intricacies of creating and
managing biomedical information

Disciplines Informing Medical Informatics The Scope of Medical Informatics

• Computer Science • Clinical Informatics

• Information Science – Informatics applied to the delivery of health care
• Cognitive Science • Knowledge Management
• Decision Science – Storing, representing, and retrieving health care
information (e.g. research evidence, practice
• Management/Organizational Behavior guidelines, etc)
• Statistics • Imaging Informatics
• Health Sciences – Informatics applied to acquiring and processing
biomedical images
• Public Health Informatics
Informatics is inherently multi-disciplinary
Lobach DF. Clinical informatics: Supporting the use of evidence in practice and relevance to physical therapy
education. J Phys Ther Educ. 2004;18(4):24-34.

Training in Medical Informatics Training in Medical Informatics
From undergraduate to PhD and post-doctoral fellowships
• Fellowships
– 19 National Library of Medicine-sponsored
programs and also through the VA
– For doctorally-prepared candidates (MDs, PhDs,
DPTs) with relevant computer experience
– Regenstrief Institute
• Intensely pragmatic

• Opportunities in industry, clinical practice,

• Rapidly promulgating idea of informatics
competencies for all health care providers

Big Picture
What is the Role of EHRs?

• EHRs are the primary building blocks

– Vehicles for delivering the info to clinicians
– Interfaces for collecting info from clinicians (and
– Repositories for storing data
A Focus on Clinical Informatics • A suite of applications and processes
– Not just one ‘program’
– Far more than electronic documentation systems
• Lots of acronyms
– No consensus definition
– IOM concept is most prevalent


An EHR Includes: Core Functionalities

1. Health information and data

1. Longitudinal collection of electronic health
information for and about persons 2. Results management
2. Immediate electronic access to person- and 3. Order entry/management
population level information by authorized,
4. Decision support
and only authorized users
3. Provision of knowledge and decision-support 5. Electronic communication and connectivity
that enhance the quality, safety, and 6. Patient support
efficiency of patient care
7. Administrative processes
4. Support of efficient processes for health care
delivery 8. Reporting and population health management

• Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System. • Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System.
Washington, DC: National Academy Press; 2003. Washington, DC: National Academy Press; 2003.

The EHR The Scientific Side of Clinical Informatics
Myriad Sources and Uses19

Sources for an EHR • All of these 8 “core functionalities” are areas of

• Critical building blocks of an EHR system active study in clinical informatics
– records maintained by providers • Informaticians
– and by individuals (AKA personal health records) – Researchers who design, implement, and study the
effectiveness of these systems
– Not the help desk guys
Primary Uses: associated with provision of care • Well-designed and useful systems require an intimate
• Providing, consuming, managing, reviewing, charging, and reimbursing care
services understanding of clinical practice demands
Secondary Uses: not necessary for a particular • Clinicians who are Informaticians
encounter – Knowledgeable about data content, format, and timing,
• Education, research and development, regulation, policy making that is important for practice
– Understand the limits of technology

19. Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System. Washington, DC: National Academy Press; 2003.

The Scientific Side of Clinical Informatics

Getting healthcare practitioners to change Where is all of this heading?

how they practice is kind of like…

National Initiatives in Clinical Informatics:

[video link]
Developing a Nationwide Health Information Network

Widespread Recognition 2006 State of the Union Address

A Brief History
• 1991 – An IOM taskforce examined issues around medical records For all Americans, we must confront the rising cost of care,
• 1997 – A follow-up report of this IOM committee strengthen the doctor-patient relationship, and help
• 1998 – National Committee on Vital and Health Statistics people afford the insurance coverage they need.
• 2002 – The Markle Foundation organizes Connecting For Health
• 2003 – DHHS begins to promote widespread use of modern HIT We will make wider use of electronic records and other
• 2003 – DHHS, DoD, VA partner in Consolidated Health Informatics health information technology, to help control costs and
• 2003 – President Bush signs the Medicare Prescription Drug reduce dangerous medical errors.
- President George W. Bush
Improvement and Modernization Act January 2006
• 2004 – President Bush makes HIT a top national priority
• 2004 – DHHS Responds

Thompson TG, Brailer DJ. The decade of health information technology: delivering
consumer-centric and information-rich health care. Framework for Strategic Action. July
21, 2004. Available: http://www.os.dhhs.gov/healthit/documents/hitframework.pdf

The Decade of Health Information Technology

Readiness for Change

Overview • The vision
– Complete, longitudinal health information follows the consumer
– Health decisions are made with information tools to assist and guide

The Decade of Health •

The (envisioned) result
Fewer medical errors

Information Technology –

Less wasteful care
Fewer variations in care
– Patient-centered care
Delivering Consumer-centric and Information-rich Health Care
– Clinicians with more time for patient care
– Employers will gain productivity and competitive edge from
reduced spending

Big Picture Big Picture

What Will This Look Like? How Will This Unfold?

• A ‘Network of Networks’ • A stepped series of initiatives

– Not a central database – Not a law
– Communication via shared set of – Not a ‘rip and replace’ approach
technical and policy requirements • Led by collaboratives with stakeholder
– Lots of ways underlying networks can form input
• Geography
• Affinity
• Benefits
– Smooth, market-led way
• Benefits
– Ensures that all relevant parties have input
– Leverage existing data pools
and can develop buy-in
– ‘All healthcare is local’

Key Challenges to Creating an NHIN Key Challenges to Creating an NHIN

• Limited adoption of EHRs • Lack of Standards

– Social / Political challenges often hardest – Silos of information
– Unequal adoption rates by practice size • Exchanging health
• Financial risk information requires:
– Uncertain ROI – Vocabulary standards
– Unequal accumulation of benefits – Messaging standards
• Threats to privacy and security – Transmission standards
• Consistent

A Quick Org Chart

Strategic Framework
Offices Agencies
• Office of the National Coordinator • AHRQ
The Decade of Health for Health Information Technology
• Office of the Inspector General

Information Technology • Others…

• Others…
Delivering Consumer-centric and Information-rich Health Care

The Decade of Health Information Technology The Decade of Health Information Technology

Strategic Framework Strategic Framework

Goal 1: Inform Clinical Practice Goal 2: Interconnect Clinicians

Central theme: bring EHRs into clinical practice which Electronic connectivity enables portable information that moves
will reduce errors, duplication, and allow clinicians to with consumers throughout the continuum of care.
focus on care delivery
This requires an infrastructure to allow information to be available
at the point and time of need.
– Strategy 1: Incentivize EHR adoption
– Strategy 2: Reduce the risk of EHR investment – Strategy 1: Foster regional collaborations
– Strategy 3: Promote EHR diffusion in rural and underserved – Strategy 2: Develop a national health information network
– Strategy 3: Coordinate federal health information systems

The Decade of Health Information Technology The Decade of Health Information Technology

Strategic Framework Strategic Framework

Goal 3: Personalize Care Goal 4: Improve Population Health

Consumer-centric care allows individuals to manage Requires timely, accurate, and detailed clinical information to
their own wellness and assist with personal health evaluate health care delivery.
Also requires efficient reporting of information to public health
officials and dissemination of clinical research findings.
– Strategy 1: Encourage the use of Personal Health Records
– Strategy 2: Enhance informed consumer choice – Strategy 1: Unify public health surveillance architectures
– Strategy 3: Promote use of telehealth systems – Strategy 2: Streamline quality and health status monitoring
– Strategy 3: Accelerate research and dissemination of

The Decade of Health Information Technology The Decade of Health Information Technology

Key Focus Areas Specific Actions

• Regional Health Information Organizations (RHIOs) • American Health Information Community

• Nationwide Health Information Network (NHIN) – Key leaders in the public and private sectors
• Driving EHR Adoption • Public Sector (VA, DoD, Dept of Commerce, etc)
– Reduce the risk of investing in EHRs • Private Sector
– Developing a certification process – Consumer and Privacy Interests
– Provide implementation support – Purchasers
– Third-Party Payers
– Hospitals
– Physicians
– Nurses
– Ancillary Services (e.g., laboratories and pharmacists)
– Information Technology Vendors
– Advises HHS

The Decade of Health Information Technology The Decade of Health Information Technology

Specific Actions Specific Actions

• E-prescribing • Key contracts to public-private groups

– CMS and OIG issued final rule on the ‘foundation – Standards harmonization
standards’ for e-prescribing – EHR certification process
– Examining policies and state laws affecting privacy and
– All Medicare prescription drug plans must support security practices
these standards
• NHIN Prototype Contracts
• Health Information Technology – 4 awards to consortia totaling $18.6 million
Adoption Initiative – Partnerships between technology developers and providers
– Each will design and implement a standards-based network
– Partnership of ONCHIT, GWU, Mass General – Regenstrief/INPC is part of one of these
– Characterizing and measuring EHR adoption rates

Agency for Healthcare Research and Quality

Goals of HIT Initiative

• Help clinicians deliver higher quality, safer

Other NHIN-Related • Put the patient at the center of healthcare
• Stimulate HIT, especially in rural and
National Initiatives underserved areas
• Identify most successful approaches and
barriers to implementation
• Make the business case for HIT by evaluating
costs and benefits

Agency for Healthcare Research and Quality Centers for Medicare & Medicaid Services

Components of the HIT Initiative HIT-Specific Initiatives

• State and Regional Networks

• Building the 21st Century Health IT “We are committed to using health information
Infrastructure technology to improve health and health care
not only for Medicare’s 41 million beneficiaries,
• Helping Rural and Small Communities but for all Americans.”
• AHRQ National Resource Center
Mark B. McClellan, MD, PhD - CMS administrator
July 2004

Medicare Payment Advisory Commission Centers for Medicare & Medicaid Services

Quotes from Report to Quality Initiatives

Congress March 2005
• Congress should establish a quality incentive Quality Improvement Roadmap (July 2005)
payment policy for physicians in Medicare • Make care safe, effective, efficient, patient-
centered, timely, and equitable
• CMS should require those who perform laboratory Pay for Performance
tests to submit laboratory values, using common • Collaboration to guide development
vocabulary standards • Initiatives developed for
– Hospitals
• Congress should direct CMS to include measures of – Physicians and integrated health systems
functions supported by the use of information – Chronic disease management
technology in Medicare initiatives to financially • APTA Annual Conference: The 2006 Rothstein Debate
reward providers on the basis of quality

Other Federal Initiatives

• National Library of Medicine
– Grants
– Development controlled clinical
What would ‘high quality’ vocabularies
• Department of Veterans Affairs
physical therapy look like? – Leader among large health systems in
using HIT successfully
• Centers for Diseases Control and
– 3 initiatives related to disease surveillance
and management

The Regenstrief Institute
• Endowed by Sam Regenstrief
– Inventor of the low-cost dishwasher
– Obsessed with process improvement
• Created the Institute in 1972
• A healthcare improvement “skunkworks”
• A community of scholars
The Indiana Network for Patient Care – Informatics unit has published more
controlled trials than any other U.S. center
a working example of interoperable health information exchange – A “benchmark” institution

• BIondich PG, Grannis SJ. The Indiana Network for Patient Care: An integrated clinical information system informed by over thirty years of experience. J Public Health
Management Practice 2004 (Nov Suppl):S81-S86.
• McDonald CJ, Overhage JM, Barnes M, et al. The Indiana Network for Patient Care: A working Local Health Information Infrastructure. Health Affairs. 2005;24(5):1214-1220.

Initial Goals - Circa 1972 A Brief History

1. Eliminate the logistic problems inherent in the paper • 1972 – Regenstrief Medical Record System (RMRS)
record • 1974 – The first operational reminder system
• 1976 – RCT showing benefit of computerized
2. Reduce the work of clinical “book keeping” required reminders
to manage patients • 1986 – “Smart” physician order entry system
• 1988 – Clinical exchange standard (ASTM 1238)
3. Make the information “gold mine” available for • 1993 – 1st (and only) RCT of inpatient CPOE
clinical, epidemiologic, public health, outcomes, and • 1994 – Early city-wide network
management research • 1995 – LOINC – a universal code system for
laboratory and clinical variables
These same goals continue to direct the continuing • 2003 – Working to expand INPC to entire state
development of the INPC 30 years later

• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.
• Tierney WM, et al. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA. 1993;263(3):379-383.

Present Day INPC Participants Overview of Participation

• 1972 – Wishard Health Services • Five major Indianapolis hospital systems
– 15 hospitals
• 1989 – Indiana University Hospital – 95% of hospital and ER care in Indy
• 1995 – Methodist and Riley Hospitals • Three hospital-associated group practices
• 1999 – Community Hospitals – 35% of outpatient practices
• 2000 – St. Vincent Hospitals • Both major cardiology referral centers
• Four homeless clinics
• 2002 – St. Francis Hospitals
• County and State health departments
– Immunization records, lab results, tumor registry
• National and regional laboratories

The INPC started with the aim of improving emergency

department care. It continues to expand with projects
consistent with the initial Regenstrief goals (1972).

Indy ED Registration Crossover
Hospital Systems Percent Overlap
One 40%

Two 39%
Three 18%
Four 3%
Five <1%

60% of patients have received some level of care

in more than one hospital system

National Health Information Network



Minimum Contribution to INPC A “Huge” Repository

• All INPC Institutions contribute (at minimum): • Stored in the system
– 660 million discrete observations
– Discharge/Admission summaries – 45 million radiology images
– Radiology reports – 14.5 million text reports
– Operative notes – 450,000 EKG tracings
– Pathology reports
• Greater share of data come from Wishard
– Medication records
and IU Hospitals
– EKG reports
• In 2004, 92 source systems

Indiana Network for Patient Care
Identifying Patients and Providers
Laboratories, etc
• ‘Global patient registry’ creates virtual record
– Sophisticated mechanisms “link” data
St. Vincent IUMG
– Based on fuzzy matching algorithms
– Clinician has the final say in whether to merge the
data for viewing or not

Global Patient Concept Global Provider State/County • A similar mechanism matches providers across
St. Francis Index Dictionary Index
Health Departments
– INPC doesn’t “create” access
– It only makes it easier to use
– Approved access uses is evolving
Clarian Community
Wishard Memorial

Where Do the Data Come From? Consolidating the Silos

• Directly from instruments or electronic systems • Among “like systems”, the same content has
– Bedside vital sign devices different names
– EKG carts
– CXR, Chest XR, Chest x-ray
– Laboratory systems – Quite literally, a Tower of Babel
– Radiology systems
– Cardiac echo • In order to consolidate data across sources:
– OB Ultrasound
– Appointment scheduling Each idiosyncratic code from a source system is
– Dictation/transcription systems
mapped to a common term in a “Master Dictionary”
• Directly or indirectly from practitioners
– Both structured and “free text” narrative
– We are mindful of how burdensome this can be
• Entered electronically by providers directly
• Optically read by the computer from paper forms
• Manually entered from handwritten notes on paper forms
• The Master Dictionary is based on accepted
Even within an institution, data reside in silos standards, which provide the lingua franca

Clinical Vocabulary Standards Organizational Structure

• The Regenstrief (INPC) Master Dictionary • Collaboration has evolved over time
employs: – Trust takes a long time to develop (years!)
• INPC Management Committee
– LOINC for laboratory and clinical observations – Representatives from each participating institution
– CPT-4 for procedures
– ICD-9 for diagnoses • INPC operates under a mutual contract
– NDC and RxNorm for medications – HIPAA business associate agreement
– SNOMED/UMLS for organisms in microbio results – Permits de-identified research
• Except if it compares institutions or providers
• Regenstrief is a neutral, 3rd party convener
– The “Data Switzerland”
• Gathers and standardizes data
• Develops and maintains the computer systems

A Related Organization
• Indiana Health Information Exchange (IHIE)
– Non-profit organization created in 2004
– Goal is to support the INPC infrastructure by creating a

sustainable business model
IHIE Board
Clinical Uses of the INPC
• Mayor’s office, BioCrossroads, Marion County and IN State
Public health departments, state and county medical societies, Database and the
Associated Tools
CEOs of the major hospital systems, other leaders

A Unified Medical Record

Results Inquiry - CareWeb
Clinical Flowsheet

Clinical Flowsheet - Graphical EKG – Raw Coded Data

EKG Tracing Radiology Reports

A Unified Medical Record

Radiology Images Other Outputs For Clinical Care

• Patient Abstracts
– Outpatient views
– Customized for clinical location
• ER vs newborn vs pediatrics
• Encounter Forms
– A form for clinicians to document care
– Can contain computer-generated
reminders, alerts, etc
• Tailored Documents
– “Pocket Rounds”

Pocket Rounds Pocket Rounds

The Medical Gopher The Medical Gopher
Clinical Work Station Application Clinical Work Station Application
• A work station application at Wishard • Informed by 30 years of clinical data
Memorial Hospital and Clinics • Extensive Clinical Decision Support
• Capabilities for – Contraindicated meds
– Prescriptions, Orders, Problems, Clinical notes – Allergies
• In return – Reminders for vaccinations, etc
– Hints / Reminders – Prevents errors of omission with order sets
– Alerts • Auto-generates corollary orders for monitoring
– Secure email
– Rapid access to relevant information
• Patient specific
• A “mini library”
– Formulary info
– Directories

The Medical Gopher Report Delivery Services

Clinical Work Station Application DOCS4DOCS®
• Routes reports from INPC sources to
appropriate clinicians throughout the network
• Key Features
– Standardizes the report format
– Alerts the practice to new reports
– Can be delivered by a variety of media
• WWW, fax, email
– Practices have lots of options about what kinds of
reports they want to view
– Annotates reports that have been viewed

Child Health Improvement through Child Health Improvement through
Computer Automation (CHICA) Computer Automation (CHICA)

• Outpatient Decision Support System

• Integrates easily into the clinical workflow
• Delivers relevant, high priority, tailored
reminders & content for providers at actual
point of care
• Captures structured clinical data
• Provides a familiar, intuitive, easy to work
with, portable, inexpensive, flexible interface

Vital Sign Calculations

Sample Sample
Form (PSF) Physician

Physician’s Worksheet

Vital Sign Calculations


Physician’s Worksheet

Screening Identifying More PWS
Form (PSF) Risk Factors Features
• Physical exam
• Also duplex..

Physician’s Worksheet Reminder

Reportable Disease Module

• Supports public health reporting of notifiable

– Examines incoming HL7 messages

Public Health and –

Looks for reportable condition data
If conditions are met, extracts patient and provider

Research Uses of the INPC

information from INPC data
– Automatically transmits data to Health Department
– Interested parties receive daily email summary
• Recent Analysis
– Electronic reporting captured 5X more data than traditional
– Reporting was significantly more timely

Reportable Disease Module Public Health Reportable Diseases

Abnormal flag,
Realtime Compare to Dwyer Organism name Daily Batch
Table I content in Dwyer II, or
(LOINC codes) Value above To Public
threshold Health
Potentially Reportable Conditions
Reportable Condition Databases
To Infection

Record Count
as denominator

Biosurveillance Clinical Research Usage
• In process of building a network to capture chief • Over 2,000 active studies at IU use INPC data
complaint data from all 140 hospital ERs in IN
• Electronic Tools
• Chief complaint data fed into algorithms to detect
– Fast Retrieval for “quick answers” and “first looks”
and monitor for bioterrorism and outbreak detection
– Shared Pathology Informatics Network (SPIN)
• More than 60 hospitals are now connected
• Links pathology specimens with clinical data
• Tools for conducting de-identified research
Event: Time • Epidemiologic Studies
Weekly ED Gastrointestinal Syndromes
– Association of erythromycin and pyloric stenosis
among newborns
Signal: Alarm

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

• Mahon BE, Rosenman MB, Leinman MB. Maternal and infant use of erythromeycin and macrolide antibiotics as risk factos for infantile hypertrophic pyloric stenosis. Journal of Pediatrics. 2001;139(3):380-384.

Lessons Learned
• Start with things that add value/information
• Recognize that different data sources require
different standardization efforts
Keys to Success and • Commitment to standards

Lessons Learned • Achieving a critical mass – get more bang

for your integration buck
– Leverage the value of integrated data
• Understanding clinical workflow
• Managing sociopolitical challenges

Evidence for EHRs in Physical Therapy

• Discussion of Vreeman et al paper

– Key findings
– Recommendations
Implications of Clinical – Discussion of issues raised in commentary
Informatics for Physical Therapy

Current Related APTA Initiatives

• Hooked On Evidence
– Online database of article summaries relevant to
interventions used by physical therapists Proposed Competencies and
– Accuracy?
Clinical Informatics
• APTA CONNECT Educational Content for
– a point-of-care, computerized patient record
system designed specifically for physical therapists
Physical Therapy
– Includes the ability to collect outcomes measures
that will be used to generate a national database
• OPTIMAL, SF-36, Oswestry, etc
Lobach DF. Clinical informatics: Supporting the use of evidence in practice and relevance
– For outpatient, PT-only practices to physical therapy education. J Phys Ther Educ. 2004;18(4):24-34.

Content for Physical Therapy Education Content for Physical Therapy Education
Computer Literacy •Skill with office productivity software

• Discussion of Lobach paper •Internet use for various applications + searching for health info
•PDA use

Information Retrieval •Develop and use search strategies for accessing professional literature
•Access and use online textbooks
•Organize electronic information for future access

Data Representation •Understand advantages/disadvantages of coded versus free form data

•Use of PT-related coding systems (ICD9, CPT, ICF?, LOINC?)
•Awareness of available terminologies and nomenclatures for healthcare

Information Management •Familiarity with data modeling and data flow concepts
•Database principles and use for health information
•Awareness of data warehousing and data mining concepts
•Use of aggregate data for quality assessment and population health
•Understand issues related to data security

Health Care Information Systems •Exposure to diverse clinical information systems

•Familiarity with advantages and limitations of EHRs
•Awareness of EHR components, breadth of functionality from EHRs
•Awareness of standards related to exchanging data between systems
•Understanding of benefits/limitations of regional information system networks

Clinical Decision Support Systems •Understanding of various approaches to using information systems for decision support
•Awareness of the role of information systems in decision making
•Understand the value of information systems to support EBP

Networking •General understanding of basing Internet network architecture (e.g. TCP/IP)

•Awareness of the role of Internet communication protocols

Telehealth •Awareness of technology for practicing health remotely

•Understanding of the benefits and limitation of telehealth applications
Lobach DF. Clinical informatics: Supporting the use of evidence in practice and relevance to physical therapy education. J Phys Ther Educ. 2004;18(4):24-34.

• Office of the National Coordinator for Health
Information Technology (ONCHIT).

• American Medical Informatics Association

(AMIA). http://www.amia.org