HAN 364 Midterm

Patient Summary Standards

Continuity of Care Document (CCD) based on HL7 Version 3 and Clinical Document Architecture -Stage 2 of the Meaningful Use criteria (health information exchange)

Organizations Involved with HIT

Department of Health and Human Services (HHS) Office of the National Coordinator (ONC) Agency for Healthcare Research and Quality (AHRQ) Health Resources and Services Administration (HRSA) National Institute of Standards and Technology (NIST)

**Different Types of HIEs

Directed HIE Query-based HIE Consumer mediated

Computer Hardware

Fetches instruction; codes and decodes into binary instructions -executes actions -stores writing outputs to memory Central Processing Unit (CPU): where computer chip resides and related to data processing speed Random Access Memory (RAM): the working memory that is lost when the computer is turned off; requires continuous power to maintain it Input/output devices: output: monitors and printer input: keyboards, mouse, and speech

HITECH Act and EHR Reimbursement Continued

For clinicians to participate they had to: 1. be eligible 2. register for reimbursement 3. use a certified EHR 4. demonstrate and prove Meaningful Use 5. receive reimbursement

**Health Information Exchange Continued

HITECH Act recognized that EHR adoption was insufficient to realize the full promise of HIT -HIE is a critical element of Meaningful Use, ACOs, and Patient Centered Medical Homes (PCMHs) as well as integral to the future success of healthcare reform at the local, regional and national level -the federal gov't has been a major promoter of HIE and the development of data standards to achieve interoperability

Types of Standards

Identifier Standards Transaction Standards** Messaging Standards** Imaging Standards** Terminology Standards

Knowledge Representation: Rules-based

If-then statements; if the patient is allergic to sulfa and sulfa is ordered, then an alert is triggered

Terminology Standards

International Classification of Diseases (ICDs) -codes diseases as well as the cause of death -updated annually; clinically modified because it is used for reimbursement in the US ICD-10: most of the world has been using since 1990 ICD-9: less advanced; some of the world still uses (less common)

CDS Knowledge Management

Knowledge acquisition: internal data (EHR) or external data (Apache scores) for CDS Knowledge representation: expert info., integrate it with an inference engine and communicate it to the end user (ex: an alert) Knowledge maintenance: constantly update expert evidence-based information

Transaction Standards

The National Provider Identifier (NPI)- assigned to all physicians in the US -employees have a standard Employer Identifier Number (EIN) ACA requires health plans to have either a Health Plan Identifier (HPI) or an Other Entity Identifier (OEID) that is for use in transactions

Data

"numbers" -computer data lacks meaning -includes dates and other qualifiers to gain significance -everything MUST be standardized -the systems that manage data are called database systems

Computer Software

**instructs the hardware what to do** -also SOA (Service Oriented Architecture) -program that allows for connection to web servers over the internet using hypertext transfer protocol (HTTP) -web pages written as hypertext markup language (HTML) -abstraction: knowing the short way of doing things, not having to spell it out every time -virtualization: access another computer or operating system

Meaningful Use Goals

**same as national goals for HIT 1. improve quality, safety, efficiency, and reduce health disparities 2. engage patients and families 3. improve care coordination 4. ensure adequate privacy and security of personal health information 5. improve population and public health

CDSS Functionality Continued

-Alerts and reminders: classic CDS output that usually reminds clinicians about drug allergies, drug to drug interactions and preventative medicine reminders -Relevant information displays: info buttons, hyperlinks, mouse overs -- common method to connect to evidence-based information -Diagnostic support: external and not integrated with EHR -Dashboards: summarize a patient's status and thereby summarize and inform the clinician about multiple patient aspects

Clinical Data Warehouse (CDW)

-a database system that collects, integrates, and stores clinical data from a variety of sources, including EHRs, radiology, and other information systems -highly valuable for informatics and evidence-based medical research -helps track infections and report trends to public health -can be used to evaluate a critical clinical process, cost estimates, and they can analyze potential solutions

**Regional Health Information Organization (RHIO)

-a health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange (HIE) among them for the purpose of improving health and care in that community "top guys" -not a specific region*

**HIE Data Shared: Images

-actual images and radiology reports

Computerized Physician Order Entry (CPOE)

-an EHR feature that processes orders for medications, lab tests, imaging, consults and other diagnostic tests (**not the same as e-prescribing) -has the potential to reduce medical errors (limited evidence)

RESTful Services (not a topic for exam but may be part of a question for different topic)

-an architecture, not a standard with endless possibilities as to how REST can be applied to act as a service bus 3 basic aspects: 1. URI- uniform resource identifier 2. Operation Types- GET, DELETE, POST, PUT 3. MIME Type- Multipurpose Internet Mail Extensions

Electronic Health Record (EHR)

-an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards; can be created, managed and consulted by authorized clinicians and staff across more than one healthcare organization

**Health Information Organizations (HIOs)

-an organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards -can be created for specific populations such as those on Medicaid or uninsured "second guys"

**Health Information Service Provider (HISP)

-an organization that provides services and support for the electronic exchange of health information; can be a healthcare entity, an HIO, or an IT organization

Clinical Decision Support (CDS) Systems

-any electronic or non-electronic system designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient-specific assessments or recommendations that are then presented to clinicians for consideration -to enhance health and healthcare (ONC) -technology that supports CDS: references warnings reminders

Wireless LANs (WLAN)

-cheaper -no hardwire -network router via internet by ethernet

Personal Area Networks (PANs)

-close proximity network designed to link phones, computers, PDAs -Bluetooth and personal hotspots

Computer Hardware: Auxiliary Storage

-data storage even without power Active storage: data stored that is needed constantly Archival storage: typically used as back up; cloud storage and hard drives, optical storage

Information

-data without meaning

**Directed HIE

-direct sending and receiving of information to support planned care; includes activities such as referral or transfer of patients and is sometimes called "push" HIE because the info. is pushed from one health care entity to another key words: referral/transfer of patients; push HIE

**Direct Project

-email based, secure messaging platform -ability to send health information via email -all participants need to apply/register for unique email -EHR vendors encouraged to include this function within their project

US Federal Government: The Patient Protection and Affordable Care Act of 2010

-expanded Medicaid coverage for the uninsured -created the Patient Centered Outcomes Research Initiative (PCORI) -created CMS Innovation Center that will evaluate new healthcare delivery models -created a Readmission Reduction Program that will penalize hospitals with too many readmissions

EHR Challenges

-financial -physician resistance -loss of productivity -lack of interoperability -privacy concerns -legal issues -inadequate proof of benefit: no adequate proof that EHRs improve quality of care -patient safety: pt's may not think you care about them due to standing at bedside typing; impersonal

National Academy of Medicine (NAM)

-formally known as Institute of Medicine (IOM) -evaluates policy relevant to healthcare and provides feedback to the Federal Gov't and the public -some reports they published influenced legislation, including HIPAA and HITECH

Local Area Networks (LANs)

-generally link computers in an office, hospital, home, or close proximity situation (**physically connects several computers) -nodes (computers, printers) connecting technology (wired or wireless) and specialized equipment such as hubs, routers, and switches

Programming Language

-gives instructions to the hardware telling it how to move and manipulate data Examples: C, C++, C#: used in many modern applications MUMPS (now known as M): used in many early medical applications; many modern enhancements (currently) BASIC: common in early days of PC Python: originated as "scripting" languages ; achieving larger-scale use Java: attempt to create standard language for Web applications JavaScript: scripting language for statistics and data analytics

**Blue Button Project

-health consumer in control -download their records and results Meaningful Use mandates data sharing so HIOs can assist

Why Health IT Fails Sometimes

-health information technology is the application of computers and technology on healthcare settings -might not be realistic -ups and downs with artificial intelligence -large gap between healthcare data generated and information (semantic gap)

CDS Benefits and Goals

-improve patient safety -improve patient care -reduction in healthcare costs -population health -dissemination of expert knowledge -management of complex patients -clinical monitoring -clinical research

Knowledge

-information that is justifiable; believed to be true -covert medical information to knowledge is to use a Clinical Data Warehouse (CDW) -interpreting free text requires Natural Language Processing (NLP)

Center for Medicare and Medicaid Services (CMS)

-insurer for about 100 million Americans -reimburses for "Meaningful Use" of certified EHRs by clinicians and hospitals under Medicare and Medicaid key words: reimburses; medicare and medicaid

**Query-based HIE

-involves a query process to find info. that may be unknown to the provider; an example is when a patient visits the ED; also known as a "pull" HIE key words: find unknown info; Pull HIE

CPOE Continued

-it is difficult to implement in hospitals because it disrupts workflow and slows physicians down; they often don't realize the benefits of CPOE for other in the team, like nurses and pharmacists

Knowledge Representation: Configuration

-knowledge represented by choices made by the institution

**HIE Data Shared: Clinical Results

-lab, pathology, medication, allergies, immunizations, and microbiology data

**HIE Barriers

-lack of successful business models -environment is highly competitive -federal support monies are gone -HIOs seem to work better in high population areas -return on investment (ROI) is unclear -proof of benefit is weak -privacy/security issues

Meaningful Use Outcomes

-little evidence to suggest that meaningful use programs have improved patient outcomes, as opposed to patient processes -CMS Innovation Center launched a program that will pay more attention to outcomes called Comprehensive Primary Care Plus (CPC+) - participants will focus on improving access, continuity and population health

CDS Action Steps

-might be overriding the alert or cancelling an order for a drug to which the patient is allergic

Electronic Patient Registries

-modern registries tend to fall into the following categories: 1. chronic disease: for tracking purposes 2. research registries: high volume allows research questions to be answered; can be used to evaluate and compare different outcomes 3. safety registries: issues reported to [ex: FDA] 4. Public health registries: immunizations, cancer, and biosurveillance 5. Quality registries: data could be stored in registry and later forwarded to [ex: CMS]

** Healthcare Data Potentially Shared

-most commonly involves the exchange of clinical results, images, and documents; important to share financial and administrative data among disparate entities Common types of health related data: Clinical Results Images Documents Clinical Summaries Financial Information Medication Data

HL7 Standards: Clinical Document Architecture (CDA)

-most healthcare information is in the form of documents, and these are used to allow humans to read them -key aspect of CDA is templates; current version of CDA has 3 levels of interoperability: 1. general document specification 2. adds document types with allowable structures 3. adds mark-up expressible in structured form, such as RIM (Reference Information Model)

Imaging Standards

-moving image data from devices that capture the data into records, so they can be viewed and archived in various ways -Digital Imaging and Communications (DICOM) standard is intended for the transportation of images

**Opt-in

-no health information can be exchanged unless the patient signs a specific informed consent document permitting the sharing of data

Barriers to HIT Adoption

-not enough time -not enough expertise -not enough financial resources -lack of interoperability between technologies -inadequate cost and return on investment data -privacy concerns -need for behavioral changes

**Health Information Blocking

-occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information

CDSS Functionality

-order sets: EHR templated commercial or home grown orders that are modified to follow national practice guidelines -therapeutic support: includes commercial products such as Theradoc and calculators for a variety of medical conditions -smart forms: templated forms, generally used for specific conditions such as diabetes; they can include simple check the boxes with evidence-based recommendations

Potential Benefits of CPOE

-overcomes issue of illegibility -fewer errors with ordering drugs -easily linked to drug-drug interaction warning -more likely to identify the prescribing physician -creates data that is available for analysis -can reduce under and over- prescribing -can point out treatment and drugs of choice

Why Do We Need EHRs?

-paper records are severely limited -need for improved efficiency and productivity -quality of care and patient safety -public expectations -government expectations -financial savings -technological advances -need for aggregated data: healthcare data must be electronically shared, stored and analyzed -need for coordinated care

Affordable Care Act (ACA 2010)

-primary goal was to increase insurance coverage by expanding private and Medicaid coverage to reduce healthcare costs and to improve patient outcomes Other areas within the ACA include: -CMS Innovation Center that evaluates ACOs -Readmission Reduction Program -Value-based reimbursement to hospitals and physicians based on quality measures

Clinical Decision Support (CDS)

-provides clinicians staff and patients with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and healthcare

Messaging Standards

-reading/interpreting messages from different health resources -focus on different types of messages and different types of data HL7 (Health Level 7) is the organization that develops and supports standards and is properly called HL7 international

**Opt-in and Opt-out

-refers to patient consent policies; the ability for content creators determine whether the personal health record data they create can be shared as well as with whom

HITECH Act included financial support for:

-reimbursement for use of certified EHRs -state health information exchange -comparative effectiveness research

Interoperability

-standards facilitate an important process known as interoperability -defined by the Institute for Electronic and Electrical Engineers (IEEE) as "the ability of a system or product to work with other systems or products without special effort on the part of the customer; made possible by the implementation of standards"

What Makes Informatics Difficult?

-subjective factors ("i feel sick") that are difficult to measure and vary from patient to patient and physician to physician -it is difficult to model all of healthcare -biomedical info. is difficult due to incomplete, imprecise, vague, inconsistent, and uncertain info.

**Interoperability Levels

-successful HIE is dependent on multiple interactions between disparate partners and organizations; interoperability must occur at several levels: 1. Foundational: refers to the technology or platform used to exchange information 2. Syntactic: means messages have a structure and syntax that is understandable; uses XML and HL7 standards 3. Semantic: terminology and coding must be the same for sending and receiving organizations

Center for Disease Control and Prevention (CDC)

-support the Public Health Information Network -use HIT to improve and maintain public health using a variety of surveillance programs key words: public health

**Sequoia Project

-supports the following initiatives: eHealth exhange: group of federal and private organizations that share data Carequality: trust framework to connect current and future healthcare data sharing networks; goal is to have more than just one network (eHealth exhange) RSNA Image Share Validation: tests vendor compliance for exchange of medical images

**Statewide Health Information Exchange Cooperative Agreement Program (SHIECAP)

-the HITECH Act established funding for HIE within and across state lines -the goal was to align with national HIT policy and support Meaningful Use goals -program ended

Wisdom

-the critical use of knowledge to make intelligent decisions

Wired LANs

-to connect several computers; routers direct messages between computers -to connect several computers in a home or office, a hub or network is needed (routers direct messages between networks and the internet; switches connect computers to one another and prevent delays) - physical cord

Global Area Network (GANs)

-unlimited geographic area -4G network, cellular data

Standards Development

-usually private nonprofit organizations: American National Standards Institute (ANSI) -accredits Standards Development Organizations (SDOs) including those who work in healthcare Focused areas in healthcare: 1. Accredited Standards Committee (ASC X12) focuses on business transaction 2. Health Level 7 (HL7) focuses on messaging standards 3. The American Society for Testing and Materials (ASTM) develops health IT related standards

Third goal (stage) of Meaningful Use

-was intended to be implemented in 2018, but instead Medicare providers will transition to Quality Payment Program (QPP) that is a part of the Medicare Access and CHIP Reauthorization Act (MACRA)

Consumer Based HIE

-where consumers aggregate and control their own information -currently uncommon key words: their own information

Messaging Standards: Fast Health Interoperability Resources (FHIR)

-with the widespread adoption of EHRs and other clinical data systems, a new robust interoperability standard was needed -HL7 International took over its development

The Five Rights of CDS

1. The right information 2. To the right person 3. In the right format 4. Through the right channel 5. At the right time

4 Levels of Interoperability

1. no interoperability; ex: mail, fax, phone 2. machine-transportable (structural) information cannot be manipulated; ex: scanned document, image, PDF 3. machine-organizable (syntactic) sender and receiver must understand vocabulary; ex: email, files in proprietary format 4. machine-interpretable (semantic) structured messages with standardized and coded data; ex: coded results from structured notes, lab, problem list

HL7

2 versions: HL7 Version 2: widely used throughout healthcare and is supported by most vendors; mostly a syntax (sender and receiver must understand the meaning of the messages) HL7 Version 3: an attempt to introduce semantics into messaging; based on Reference Information Model (RIM)

Accomplishing Meaningful Use Goals (stressed by the ARRA)

3 Processes: 1. E-prescribing 2. Health Information Exchange 3. Production of reports

American Recovery and Reinvestment Act (ARRA 2009)

5 broad goals: 1. improve medical quality, patient safety, healthcare efficiency, and reduce health disparities 2. engage patients and families 3. improve care coordination 4. ensure adequate privacy and security of personal health information 5. improve population and public health -FROM ARRA, CAME the HITECH Act (most significant gov't initiative that affected the field of informatics)

Transmission Performance: Data transfer affected by:

Bandwidth: the size of the pipe to transmit packets (a formatted data unit carried by a packet mode computer network) Packet loss: is an issue because packets may rarely fail to reach their destinations End-to-end delay: the latency or delay in receiving a packet; with fiber optics latency is minimal Jitter: the random variation in packet delay and reflects internet spikes in activity

Knowledge Representation: Bayesian Networks

Bayes Theorem of conditional probabilities it predicts future (posterior) probability based on pre-test probability or prevalence

Service Oriented Architecture (SOA) (not topic on exam but may be part of a question for a different topic)

a protocol standard for interacting with web services -a set of standards for content and a SOA stack, collection of services -3 basic platform elements: 1. SOAP- Simple Object Access Protocol: communication protocol between applications 2. WSDL- Web Services Description Language: XML document used to describe and locate web services 3. UDDI- Universal Description, Discovery and Integration: a directory for storing info. about web services

**Opt-out

assumes the consumers grant permission for the exchange of personal health information as part of the broader informed consent that they sign when they receive care from a clinician and the halting of data sharing must be triggered by an action from the patient

CDS Supervised Learning

awareness of data catagories -predictive uses: age, gender, diagnosis

Bioinformatics

concerned with biological data, particularly DNA and genomic information (cellular and molecular processes)

CDS Unsupervised Learning

data is uncatagorized -no differentiation of subcategories -looks for new patterns and learning

**Health Information Exchange (HIE)

defined as "reliable and interoperable electronic sharing of clinical information among physicians, nurses, pharmacists, other health care providers, and patients across the boundaries of health care institutions, health data repositories, states and other entities who are not within a single organization or among affiliated powers" "little guys" key words: electronic movement

Health Information Technology (HIT)

defined as the application of computers and technology in healthcare settings

Biomedical Informatics

encompasses bioinformatics as well as medical, dental, nursing, public health, pharmacy, medical imaging and research informatics

CDS Knowledge Use

involves these steps: triggers: an event, such as order for a medication input data: refers to information within, such as in the EHR, might include patient allergies Interventions: the CDS actions such as displayed alerts

Systematized Nomenclature of Medicine: Clinical Terminology (SNOMED-CT)

medical vocabulary commonly used in software applications, including EHRs -more convenient way to index and retrieve medical info.

ONC for Health Information Technology

oversees application of HIT, mostly focuses on the adoption of EHRs led to the implementation of HITECH Act (Health Information Technology for Economic and Clinical Health) funding through ARRA- incentives for EHR adoption

Virtual Private Network (VPNs)

personal device/home computer can connect with a network from another location -healthcare facility: providers accessing EHR at home

Knowledge Representation: Table-based

rules are stored in tables, such as if a current drug in a patient is in one row and an order for a second inappropriate drug is stored in the same row, an alert is triggered for the clinician

Transaction Standards Continued

set of transaction standards for healthcare called ASC X12N -developed to encourage electronic commerce for health claims, simplifying what was previously a situation of over 400 different formats between insurance companies and others for healthcare transactions -HIPAA legislation mandated the use of the ASC X12N standards for healthcare business electronic data exchange under the guide of "administrative simplification"

**Interoperability

the ability of two or more systems or components to exchange information and to use the information that has been exchanged; this implies that the data is computable and that standards exist that permit interoperability

Health Informatics

the field of information science concerned with management of healthcare data and information through the application of computers and other technologies

Health Information Management (HIM)

traditionally focused on the paper medical record and coding; EHR's HIM specialists now deal with a new set of issues, such as HIPAA and legal implications of electronic data

HITECH Act and EHR Reimbursement

U.S. Federal Gov't states EHRs are an important part of healthcare reform -HITECH Act established in 2009, as part of the ARRA (American Recovery and Reinvestment Act)