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Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
Olola ph ddefenseuou10052009_final3
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Olola ph ddefenseuou10052009_final3

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PhD defense presentation

PhD defense presentation

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  • Thanks to everyone for coming to my defense…welcome. The title of my project is “Enhancing continuity of care using emergency medical card and continuity of care report”.
  • This will be the outline of my presentation today. I’ll start with some introduction followed by background of the project . I’ll then describe details of the project’s implementation, it’s evaluation and finally finish with conclusions.
  • 1st Introduction….
  • The majority of the healthcare systems are still complex & fragmented
    Partially attributable to slow implementation & adoption of EMR (approx. 17-20% of US outpatient clinics have comprehensive [fully computerized clinical notes, CPOE, lab orders and test reporting) EMRs
    Results in ineffective patient care

    Patients often see multiple healthcare providers
    Core info is needed at point of care for decision making
    They see multiple HCPs e.g. because of
    Changes in health plans
    High cost of care
    Healthcare provider (HCP) inaccessibility
    Poor patient-HCP trust, relationship
    Multiple number of HCPs seen
    Multiple visits to HCPs  Multiple records
    RESULT: Causes of discontinuity of care

    ≈44,000 – 98,000 Americans die annually
    Errors & ADE as result of poor quality information4,5

  • Types of CoC
    ----------------
    Informational or referral continuity
    Existence of shareable and organized patient core information among providers.
    Longitudinal or site continuity
    Team-based or “medical home” (continuity where patients have groups of preferred providers that they see for medical care).
    Interpersonal or provider continuity
    Where patients have providers with whom they have developed trust, respect and understanding.

    Measuring CoC
    -----------------
    No. of patient visits, illness episodes (as a fraction of scheduled or unscheduled visits).
    No. of missed appointment (rates).
    No. of duplicated tests, procedures & physical examinations.
    No. of sources of care, referral letter return rate, patient dropout rate from screening or preventive programs.
    Patient, staff and physician attitudes/satisfaction.
    Others: several continuity of care indices –COCI, MMCI, UPC etc.


  • use of a single primary HCP,
    directly observed treatment (DOT) to ensure compliance (i.e., where HCPs meet physically with patients to administer therapy),
    bar codes,
    radio frequency identification (RFID) technology ,
    Regional Health Information Organizations (RHIOs) that share health information among providers in a given geographic region are also promising but they are still faced with insufficient participation in sharing data and support the ongoing effort.[27, 28]
    pocket-sized smart card (i.e., a card with an embedded microchip/integrated circuit that can be loaded with data),
    Emergency medical cards (EMCs) …..our FOCUS.
    Continuity of care record (CCR) …..our FOCUS.

    Probems with these methods/tools
    lack of info standadization
    Poor or doubtful/distrustful data quality
    (for documents) illegibility, lack of adequate space for info (content)


    23. Fry EA, Lenert LA. MASCAL: RFID Tracking of patients, staff and equipment to enhance hospital response to mass casualty events. AMIA Annu Symp Proc 2005; 261-5.
    24. Huang P, She CC, Chang P. The Development of a patient-identification-oriented nursing shift exchange support system using wireless RFID PDA techniques. AMIA Annu Symp Proc 2005; 990.
    25. Auber BA, Hamel G. Adoption of smart cards in the medical sector: the Canadian experience. Soc Sci Med 2001; 53(7): 879-94.
    26. Cocei HD, Stefan L, Dobre I, Croitoriu M, Sinescu C, Ovricenco E. Interoperable computerized smart card based system for health insurance and health services applied in cardiology. Stud Health Technol Inform 2002; 90: 288-92.
    27. Yasnoff WA, Humphreys BL, Overhage JM, Detmer DE, Brennan PF, Morris RW, Middleton B, Bates DW, Fanning JP. A consensus action agenda for achieving the national health information infrastructure. J Am Med Inform Assoc 2004; 11: 332–338.
    28. Adler-Milstein J, McAfee AP, Bates DW, Jha AK. The state of regional information organizations: Current activities and financing. Health Affairs 2008; 27(1): w60-w69.
    29. American Standard for Testing and Materials (ASTM): E2369-05 Standard specification for continuity of care record (CCR). ASTM International, West Conshohocken, PA. July 17, 2006.
    30. Ferranti JM, Musser RC, Kawamoto K, Hammond WE. The Clinical document architecture and the continuity of care record: A Critical analysis. J Am Med Inform Assoc 2006; 13: 245–252.
    31. QUIK-SCRIPT™. The QUIK-SCRIPT emergency medical card. www.quik-script.com. Accessed December 31, 2008.
    32. Engelbrecht R, Hildebrand C. DIABCARD a smart card for patients with chronic diseases. Clin Perform Qual Health Care 1997; 5(2): 67-70.
    33. Division of Emergency Medical Services, City and County of Honolulu, Hawaii. Emergency medical ID cards. 2002-2008. www.co.honolulu.hi.us/esd/ems/emedid.htm. Accessed December 31, 2008.
    34. Dorda W, Duftschmid G, Gerhold L, Gall W, Gambal J. Austria's path toward nationwide electronic health records. Methods Inf Med 2008; 47(2): 117-23.
    35. Resource Design Group, Independent Living Resource Center San Francisco. Tips for creating an emergency health information card. www.preparenow.org/tipcrd.html. Accessed December 31, 2008.
    36. British Columbia Medical Association. Emergency medical card. BCMA, 2003. https://www.bcma.org/emergency-medical-card. Accessed December 31, 2008.
    37. Go Fast Video. Emergency medical card template - excellent to carry with you when you ride/drive. 2004. www.gofastvideo.com/gallery/item/predownload/718/1/free-racing-videos/emergency-medical-card-template.html. Accessed December 31, 2008.
    38. Paris PM, Stewart RD, Pelton GH, Porter G, Sanzo A. Triage success in disasters: dynamic victim-tracking cards. Am J Emerg Med 1985; 3(4): 323-6.
    39. West Valley City Hall, West Valley City, Utah. Vial of life. http://www.wvc-ut.gov/index.asp?NID=644. Accessed December 31, 2008.
    40. Liu C.T., Yang P.T., Yeh Y.T., Wang B.L. The impacts of smart cards on hospital information systems – An investigation of the first phase of the national health insurance smart card project in Taiwan. Int J Med Inform. 2006 Feb;75(2):173-81.
  • REF: 23-40

    use of a single primary HCP,
    directly observed treatment (DOT) to ensure compliance (i.e., where HCPs meet physically with patients to administer therapy),
    bar codes,
    radio frequency identification (RFID) technology ,
    Regional Health Information Organizations (RHIOs) that share health information among providers in a given geographic region are also promising but they are still faced with insufficient participation in sharing data and support the ongoing effort.[27, 28]
    pocket-sized smart card (i.e., a card with an embedded microchip/integrated circuit that can be loaded with data),
    Emergency medical cards (EMCs) …..our FOCUS.
    Continuity of care record (CCR) …..our FOCUS.

    Probems with these methods/tools
    lack of info standadization
    Poor or doubtful/distrustful data quality
    (for documents) illegibility, lack of adequate space for info (content)


    23. Fry EA, Lenert LA. MASCAL: RFID Tracking of patients, staff and equipment to enhance hospital response to mass casualty events. AMIA Annu Symp Proc 2005; 261-5.
    24. Huang P, She CC, Chang P. The Development of a patient-identification-oriented nursing shift exchange support system using wireless RFID PDA techniques. AMIA Annu Symp Proc 2005; 990.
    25. Auber BA, Hamel G. Adoption of smart cards in the medical sector: the Canadian experience. Soc Sci Med 2001; 53(7): 879-94.
    26. Cocei HD, Stefan L, Dobre I, Croitoriu M, Sinescu C, Ovricenco E. Interoperable computerized smart card based system for health insurance and health services applied in cardiology. Stud Health Technol Inform 2002; 90: 288-92.
    27. Yasnoff WA, Humphreys BL, Overhage JM, Detmer DE, Brennan PF, Morris RW, Middleton B, Bates DW, Fanning JP. A consensus action agenda for achieving the national health information infrastructure. J Am Med Inform Assoc 2004; 11: 332–338.
    28. Adler-Milstein J, McAfee AP, Bates DW, Jha AK. The state of regional information organizations: Current activities and financing. Health Affairs 2008; 27(1): w60-w69.
    29. American Standard for Testing and Materials (ASTM): E2369-05 Standard specification for continuity of care record (CCR). ASTM International, West Conshohocken, PA. July 17, 2006.
    30. Ferranti JM, Musser RC, Kawamoto K, Hammond WE. The Clinical document architecture and the continuity of care record: A Critical analysis. J Am Med Inform Assoc 2006; 13: 245–252.
    31. QUIK-SCRIPT™. The QUIK-SCRIPT emergency medical card. www.quik-script.com. Accessed December 31, 2008.
    32. Engelbrecht R, Hildebrand C. DIABCARD a smart card for patients with chronic diseases. Clin Perform Qual Health Care 1997; 5(2): 67-70.
    33. Division of Emergency Medical Services, City and County of Honolulu, Hawaii. Emergency medical ID cards. 2002-2008. www.co.honolulu.hi.us/esd/ems/emedid.htm. Accessed December 31, 2008.
    34. Dorda W, Duftschmid G, Gerhold L, Gall W, Gambal J. Austria's path toward nationwide electronic health records. Methods Inf Med 2008; 47(2): 117-23.
    35. Resource Design Group, Independent Living Resource Center San Francisco. Tips for creating an emergency health information card. www.preparenow.org/tipcrd.html. Accessed December 31, 2008.
    36. British Columbia Medical Association. Emergency medical card. BCMA, 2003. https://www.bcma.org/emergency-medical-card. Accessed December 31, 2008.
    37. Go Fast Video. Emergency medical card template - excellent to carry with you when you ride/drive. 2004. www.gofastvideo.com/gallery/item/predownload/718/1/free-racing-videos/emergency-medical-card-template.html. Accessed December 31, 2008.
    38. Paris PM, Stewart RD, Pelton GH, Porter G, Sanzo A. Triage success in disasters: dynamic victim-tracking cards. Am J Emerg Med 1985; 3(4): 323-6.
    39. West Valley City Hall, West Valley City, Utah. Vial of life. http://www.wvc-ut.gov/index.asp?NID=644. Accessed December 31, 2008.
    40. Liu C.T., Yang P.T., Yeh Y.T., Wang B.L. The impacts of smart cards on hospital information systems – An investigation of the first phase of the national health insurance smart card project in Taiwan. Int J Med Inform. 2006 Feb;75(2):173-81.
  • My Health clinics at design of project were 13 clinics and by start of project 25 clinics

    5 specialties: Internal Medicine, Family Practice, Endocrinologist practice, Diabetes and OB/GYN; with a total of about >120 doctors.
    The PHR system is used by over 45,000 users (was 10,000 at beginning) adult patients aged 18-90 years.

    Through an in-person registration process, patients create access credentials to enable them to view sections of Intermountain Healthcare’s EMR. The patients are also able to communicate via an inbuilt secure messaging feature with their Intermountain Healthcare Medical Group physician using templated message types.

    Intermountain maintains an architecture which seamlessly interfaces purchased or in-house developed applications to a centralized system called Health Evaluation through Logical Processing level 2 (HELP2)
  • Dearth of immediately available patient health information at the point of care, for correct medical decisions making

    Lack of standardized patient health care information to share across health systems

    Patients see multiple providers and not all providers have access to EMRs and/or to Internet
    Provide paper-based EMC/CoC report as vehicle to transport patient care information among providers
    CoC is rarely considered in most instances during patient referral, transfer or discharge6,7

    Poor quality data limit the caregivers’ ability to make correct medical decisions
    Use healthcare provider-entered (EMR) data in addition to patient-entered data to create EMC/CoC report
    Improve update process of patient information, data monitoring, identification and communication of data errors to primary healthcare providers

    Improve healthcare efficiency
    Avail timely & accurate patient information at the point of care
    Minimize waste of resources, duplication of efforts & reduce cost
  • Develop an automated application compliant with the CCR standard to enable patients to add or modify their health status information in a personal database, create and print pocket EMC and CoC report

    Simulate the use of EMC and CoC report in medical decision making (Intermountain healthcare providers)
    Dx, Rx, discharge, lab orders, data error correction/update etc

    Evaluate the impact of patient-entered data on the quality of healthcare provider (HCP)-entered data
    Accuracy, completeness, influence on EMR update

    Assess patient satisfaction with the use of the EMC & CoC report in CoC.
  • CCR standard (E2369-05)

    Developed by American Standards for Testing and Materials (ASTM)
    Originally MA Patient Care Referral Form (PCRF)
    Gathered support from many (>100) professional organizations.
    ASTM International
    Massachusetts Medical Society
    HIMSS
    American Academy of Family Physicians
    American Academy of Pediatrics
    American Medical Association
    Patient Safety Institute
    American Health Care Association
    National Association for the Support of LTC
    Additional sponsoring organizations pending
    ………
    Featured at many conferences/meetings e.g., HIMSS, TEPR…
    HL7-ASTM memorandum of understanding to harmonize CDA & CCR…Microsoft involvement too.


    Extra info ……….

    CDA vs. CCR

    Generality
    CDA is generic to all clinical documents…..intraoperability
    CCR is specific to continuity, US realm…….interoperability
    Modeling Approach
    CDA derived from RIM using HL7 v3 principles
    CCR handcrafted (ASTM model)
    Persistence (document vs. message)
    CDA persistent (header info – distribution/routing)
    CCR contains transmission-specific information
    Overlap
    Can include contents of single referral
    Both use XML for document exchange
    …CCR/CDA harmonized!
  • Phase 1: EMC project….Through Enterprise JavaBeans (EJB) services, the EMC patient-entered data is stored as an XML document in the CDR
    Phase 2: Proposed for future implementation….will provide HCPs with direct access to patient observations (in EMC database) during clinic visits.

    STEPS:

    step 1a/b: After HCPs and patients have entered data into EMR and EMC databases, data are extracted and displayed on the CCR application.;
    step 2: Data are then transformed into CCR standard’s XML format and stored in the CDR;
    step 3: The CCR XML data are extracted from the CDR;
    step 4: The EMC and/or CoC documents are generated as PDF files from the XML data;
    step 5a/b: Patients print their EMCs and/or CoC reports or save pdfs;
    step 6: Patients use the EMCs during medical emergencies and/or take the CoC reports to their primary HCPs to update information in the EMR;
    step 7: HCPs use the patient-entered data in the CoC report to update the patient information as necessary.
    step 8: After phase 2 implemented, HCPs will extract patients’ information;
    step 9: HCPs will note data discrepancies between HCP-entered and patient-entered data; and
    step 10: HCPs will finally verify and update patients’ information in the EMR.
  • Data quality:
    attributes that were excluded in the comparison comprised the emergency contact’s name and relationship, power of attorney’s name, relationship and phone, social and family history, immunization, and procedures/imaging
    2.
  • Data quality:
    attributes that were excluded in the comparison comprised the emergency contact’s name and relationship, power of attorney’s name, relationship and phone, social and family history, immunization, and procedures/imaging
    2.
  • The first promotional email message was sent out in mid November 2008 to 19,689 patients with active online access accounts in the My Health patient web portal. 83.2% (18,358/19,689) of the messages reached their destinations successfully, while the others bounced back due to inactive email addresses.
  • The usefulness of the two documents was.
    It was interesting to observe that patients between 51-60 years of age despite being the majority users of the CCR application (35%), rated the EMC and CoC report as least useful (34%) in enhancing CoC.
    On contrary, although a smaller percentage of patients between 20-30 years of age (12%), 31-40 years of age (14%), 41-50 years of age (22%) and those over 60 years of age (18%) used the CCR application, compared to those between 51-60 years of age, they rated the EMC and the CoC as highly useful (range: 43% to 83%). This demonstrated that two groups of users (i.e., the youngest - 50 years and less, and the elderly - those over 60 years) either valued the importance of quality management of CoC information more than the other users or they needed assistance with such information the most.
  • Overall, 63.1% of patients found the EMC and the CoC report to be useful in enhancing CoC
    More patients found the CoC report more useful than the EMC (63.6% vs. 62.6%) but the difference was not statistically significant.
    Agreement on the usefulness of the two documents was evident in each of the CoC measurements.
  • Transcript

    • 1. PhD Defense, October 9, 2009 ENHANCING CONTINUITY OF CARE USING EMERGENCY MEDICAL CARD AND CONTINUITY OF CARE REPORT Christopher H O Olola MSc Department of Biomedical Informatics University of Utah Committee: R Scott Evans PhD (Chair) Mollie Poynton APRN,PhD Scott Narus PhD Jonathan Nebeker MD Joseph Hales PhD
    • 2. PhD Defense 2October 9, 2009 PRESENTATION OUTLINE Introduction Background Project implementation Project evaluation Conclusions
    • 3. PhD Defense 3October 9, 2009 PRESENTATION OUTLINE Introduction Background Project implementation Project evaluation Conclusions
    • 4. PhD Defense 4October 9, 2009 CURRENT HEALTHCARE SYSTEMS Healthcare systems are complex and fragmented1,2 Partly due to slow EMR implementation and adoption3 USA: 17%-20% Outpatient clinics have comprehensive EMRs Results in ineffective patient care Patients see multiple healthcare providers (HCPs) Mostly because of changes in insurance plans, care quality, care costs, loss of trust etc Potentially results in discontinuity of care ≈ 44,000 – 98,000 Americans die annually These deaths occur because of (mostly avoidable) medical errors and ADEs as a result of poor quality information4,5 1Geissbuhler et al. 2004, 2Bates et al. 2003, 3HIMSS 2006, 4Kohn et al. 2000, 5Moore et al. 2003
    • 5. PhD Defense 5October 9, 2009 CONTINUITY OF CARE (COC) What is Continuity of Care? A process by which the patient and the physician are cooperatively involved in ongoing health care management toward the goal of high quality, cost- effective medical care. American Academy of Family Physicians – AAFP (2003)
    • 6. PhD Defense 6October 9, 2009 TYPES OF CONTINUITY OF CARE* Interpersonal or provider continuity Where a patient has a single HCP with whom s/he has developed trust, respect and understanding Longitudinal or site continuity Where a patient has groups of preferred HCPs that s/he sees for medical care i.e., Team-based or “medical home” Informational or referral continuity Where there exists organized and shareable patient core information among HCPs This is the focus of my project… *Freeman et al. 2003, Roos et al. 1980, Saultz et al. 2003 HCP: Healthcare Provider
    • 7. PhD Defense 7October 9, 2009 TECHNIQUES FOR PROMOTION OF COC* Use of a single primary HCP Directly observed treatment (DOT) Bar codes Radio frequency identification (RFID) Regional Health Information Organizations (RHIOs) Pocket-sized smart card Emergency medical cards (EMCs) Continuity of care record (CCR) This is the focus of my project… *Fry et al. 2005, Haung et al. 2005, Orlova et al. 2005, Auber 2001
    • 8. PhD Defense 8October 9, 2009 PRESENTATION OUTLINE Introduction Background Project implementation Project evaluation Conclusions
    • 9. PhD Defense 9October 9, 2009 INSTITUTIONAL REVIEW BOARDS (IRBS) All the studies in this project were approved by the University of Utah IRB and the Intermountain Healthcare IRB
    • 10. PhD Defense 10October 9, 2009 PROBLEMS/SIGNIFICANCE OF PROJECT Patients see multiple HCPs outside of Intermountain Healthcare network Dearth of immediately available patient healthcare information at the point of care Lack of standardized patient care information to share across health systems Poor quality (accuracy, completeness) patient data Healthcare inefficiencies In most instances CoC is rarely considered* *Mills et al. 2006, Post et al. 2005 HCPs: Healthcare Providers CoC: Continuity of Care
    • 11. PhD Defense 11October 9, 2009 PROJECT OBJECTIVES 1. Develop an automated application (“CCR application”) compliant with the CCR standard (E2365-05)* 2. Use simulation to assess the use and usefulness of the EMC and CoC report in enhancing CoC 3. Evaluate the impact of patient-entered data on the quality (accuracy and completeness) of HCP-entered data in the EMR 4. Assess patient satisfaction with usefulness of the EMC and CoC report in enhancing CoC *ASTM 2006 CoC: Continuity of Care CCR: Continuity of Care Record
    • 12. PhD Defense 12October 9, 2009 CONTINUITY OF CARE RECORD (CCR) STANDARD XML: eXtensible Mark-up Language DPH: Department of Public HealthASTM 2006 HeaderBodyFooter Developers: ASTM & other organizations XML-based standard Outgrowth of Massachusetts DPH patient care referral form (PCRF) Core dataset of the most relevant and timely facts on patient’s health care Originally designed to be prepared by a practitioner at conclusion of encounter To enable next practitioner to readily access pertinent patient information CCR may be prepared, displayed and transmitted on paper or electronically CCR is not EHR, Progress note, Discharge summary
    • 13. PhD Defense 13October 9, 2009 PRESENTATION OUTLINE Introduction Background Project implementation Project evaluation Conclusions
    • 14. PhD Defense 14October 9, 2009 IMPLEMENTATION OF EMERGENCY MEDICAL CARD AND CONTINUITY OF CARE REPORT FOR CONTINUITY OF CARE Olola CHO, Rowan B, Narus S, Smith M, Hastings T, Poynton M, Nebeker J, Hales J, Evans RS Methods of Information in Medicine (Accepted for publication: May 2009)
    • 15. PhD Defense 15October 9, 2009 STUDY OBJECTIVES 1. To describe the procedures used to design, develop, and implement the CCR application, EMC and CoC report using the CCR standard 2. To outline the evaluation studies planned and the major lessons learned EMC: Emergency Medical Card CoC: Continuity of Care CCR: Continuity of Care Record
    • 16. PhD Defense 16October 9, 2009 METHODS Setting and Users Develop and integrate the CCR application in the My Health patient portal at Intermountain Healthcare The application is used by approximately 30,000 patients enrolled at 25 outpatient clinics that offer My Health web services The sites have over 120 Internal Medicine, Family Practice, OB/Gyn, diabetes and Endocrinology clinicians The project took 2.5 years (December 2006 – October 2008) to implement, evaluation studies 9 months
    • 17. PhD Defense 17October 9, 2009 METHODS The Data Management Architecture Phase 1 (CCR application implementation) 1a/b: Data entry and display 2: EMC data transformed into XML & stored 3: CCR XML data are extracted from CDR 4: pdf of EMC/CoC report generated 5a/b: EMCs /CoC reports printed or saved 6: EMCs/CoC reports used with primary HCPs 7: EMR updated with patient-entered data Phase 2 (for future implementation) step 8: HCPs extract patient-entered data step 9: HCPs manages data discrepancies step 10: HCPs verifies data and updates EMR
    • 18. PhD Defense 18October 9, 2009 METHODS The Main Data Management Screen
    • 19. PhD Defense 19October 9, 2009 The Emergency Medical Card 8-faced foldable card Designed using ISO 7810 ID-1 standard (ATM card size) Contains current patient- entered data & EMR data (not differentiated) Used mainly during medical emergency
    • 20. PhD Defense 20October 9, 2009 The Continuity of Care Report Header Contains patient-entered data and HCP-entered data  All active problems, allergies, medications etc are included  3 months back (plus inactive) problems, meds, labs etc included Used mainly during non- emergency clinic visits or taken to patient primary provider to update missing or erroneous data in EMR
    • 21. PhD Defense 21October 9, 2009 RESULTS AND DISCUSSIONS An application complaint with the CCR standard requirements was designed, developed and integrated with Intermountain’s electronic PHR, My Health Patients use online credentials to access their PHRs to View, add or modify their PHRs Create and print paper-based EMC & CoC report using both patient-entered & HCP-entered EMR data Monitor records, identify possible errors and (using the CoC report) communicate to HCPs for review and EMR update Two evaluation studies were designed to assess & report on the application using simulation, reviews and comparisons of EMC/CoC report and EMR data, and patient-satisfaction surveys
    • 22. PhD Defense 22October 9, 2009 LESSONS LEARNED & STUDY LIMITATIONS EMR data update done only by primary HCPs at Intermountain is limiting – delays EMR updates & information availability at point of care Patient proxy are needed e.g., if patient is incapacitated Currently, HCPs have no direct access to patient-entered data in the CCR application database Keeping the EMC data current even if by using the unverified patient-entered data is vital PHC: Personal Health Console
    • 23. PhD Defense 23October 9, 2009 CONCLUSIONS Demonstrated that it is possible to use CCR standard to implement an application that enables patients, not only to view their PHRs but to add or modify records, & to create and print EMCs and CoC reports EMCs/CoC reports can be created using the HCP- verified EMR data & not by using patient-entered data only as is currently prevalent in healthcare systems Functionalities that enable patients to monitor their records, identify possible errors & communicate to HCPs for prompt EMR updates, are crucial
    • 24. PhD Defense 24October 9, 2009 PRESENTATION OUTLINE Introduction Background Project implementation Project evaluation Conclusions
    • 25. PhD Defense 25October 9, 2009 USE OF SIMULATION TO EVALUATE THE USE AND USEFULNESS OF THE EMERGENCY MEDICAL CARD AND CONTINUITY OF CARE REPORT IN ENHANCING CONTINUITY OF CARE Olola CHO, Narus S, Nebeker J, Poynton M, Hales J, Rowan B, LeSieur H, Zumbrennen H, Edwards AA, Crawford R, Amundsen S, Kabir Y, Atkin J, Newberry C, Young J, Hanifi T, Risenmay B, SorensenT, Evans RS Methods of Information in Medicine (Submitted: September 2009)
    • 26. PhD Defense 26October 9, 2009 STUDY OBJECTIVES 1. To use simulation to evaluate the use of the EMC and the CoC report in enhancing CoC 2. To assess the usefulness of the EMC and the CoC report in enhancing CoC EMC: Emergency Medical Card CoC: Continuity of Care
    • 27. PhD Defense 27October 9, 2009 METHODS Setting and participants (“Reviewers”) 3 Medical Doctors (MDs) & 2 Physician Assistants (PAs) from outpatient clinics at Intermountain Healthcare Clinic Managers at the Intermountain clinics made contacts 7 Fourth-year medical students from the University of Utah School of Medicine PI made contacts
    • 28. PhD Defense 28October 9, 2009 METHODS Cases of patients who entered new data using CCR application De-identified study cases (n=3) EMC CoC reportEMR 5 Complete an online survey (with Likert Scale responses) 4Review 2 Create 1Random selection 3Review • Legibility, easy to use & understand • Encounter time, overall HCP knowledge • Medical decision making
    • 29. PhD Defense 29October 9, 2009 RESULTS AND DISCUSSIONS Measure n Usefulness (agree/useful responses) in enhancing CoC EMC: n(%) RD(95%CI) p CoC report: n(%) RD(95%CI) p Sex Female 16 14(87.5) 11(68.8) Male 15 15(100.0) 0.13(-0.04,0.29) 0.484 12(80.0) 0.11(-0.19,0.42) 0.685 Designation MD/PA 13 11(84.6) 8(61.5) Medical students 18 18(100.0) 0.15(-0.04,0.35 0.168 15(83.3) 0.22(-0.10,0.53) 0.228 Specialty Family practice 8 6(75.0) 5(62.5) Internal medicine 3 3(100.0) 0.118 1(33.3) 0.086 Medical students 20 20(100.0) 17(85.0) Age of HCPs (years) 18-30 21 21(100.0) 18(85.7) 31-40 4 2(50.0) 0.026 3(75.0) 0.019 41-50 3 3(100.0) 0(0.0) 51-60 3 3(100.0) 2(66.7) Job experience (years) (mean ± SD) 31 29(5.31±7.68) 2(10.0±0.00)# 0.402 23(5.09±7.25) 8(7.13±8.54)# 0.518 RD(95%CI): Risk Difference (95% Confidence Interval) ) #Tool rated as not useful Gender, job designation, specialty and experience had no significant influence in the way the reviewers evaluated the usefulness of the EMC and CoC report Ratings significantly varied by reviewer’s age
    • 30. PhD Defense 30October 9, 2009 RESULTS AND DISCUSSIONS The reviewers provided useful comments on how the EMC/CoC report could be improved to avail adequate and appropriate information for effective medical decision making at the point of care “too many headers - condense and just list address, phone #s, no need for country”  “information is a bit confusing”  “health concerns and medications did not match - I guess this is putting the provider at fault for not adding Gout, HTN and depression to their problem list”  “Not enough information about chief complaint to be able to answer this question”  “The only important/likely pertinent health concern for this patient was hx of sepsis, rest had nothing to do with pt's plan/med probs, etc.”  “Get rid of unnecessary vital signs; pulse oximetry should be just pulse, no need for resp rate, temp, PEFR (unless has asthma); abbreviate ht and wt; get rid of pending appts, resolved allergies, past health concerns, and condense past appts to one line with reason/date”  “Condense info on CCR to 1-2 pages per patient so easy to use and worthwhile to sort through” Reviewers preferred condensed/summarized and abbreviated information
    • 31. PhD Defense 31October 9, 2009 RESULTS AND DISCUSSIONS Inter-rater agreement Measures Interpretation/Agreement (n)* EMC CoC Report Using the document Document legibility 0.49 0.58 Document understandability 0.71 0.41 Shortening of encounter time with the patient 0.47 0.80 Increase of healthcare provider’s overall knowledge 0.30 0.54 Influence of the knowledge gained from the data, on the decision to change Patient diagnosis 0.34 0.80 Patient prescription drugs or therapy 0.28 0.40 Recommendation to discharge the patient home 0.54 0.54 Recommendation to admit the patient 0.33 0.61 Recommendation to repeat the laboratory tests 0.38 0.41 Recommendation to order new laboratory tests 0.25 0.54 Recommendation to refer the patient 0.63 0.69 Recommendation to transfer the patient 0.89 0.75 Overall mean κ 0.47 0.59 Overall moderate reviewer agreement (50%-60%) on rating of EMC & CoC report Higher agreements observed in individual measures, especially for CoC report *Kappa statistics (κ) < 0 Poor or None 0.00—0.20 Slight 0.21—0.40 Fair 0.41—0.60 Moderate 0.61—0.80 Substantial 0.81—1.00 Almost perfect.
    • 32. PhD Defense 32October 9, 2009 Measures Usefulness: n=31 EMC (%) COC Report (%) Document legibility & understandability 88.7 90.3 Shorten encounter time & Increase HCP’s overall knowledge 100 100 Patient diagnosis 67.7 67.7 Patient prescription drugs or therapy 93.6 93.6 Recommendation to repeat the laboratory tests 67.9 75.0 Recommendation to order new laboratory tests 87.1 90.0 Recommendation for patient disposition* 63.4 75.0 Overall 81.2 84.5 RESULTS AND DISCUSSIONS *Discharge home, admission, referral or transfer to another HCP Overall, EMC and CoC were found to be highly useful (81.2% vs. 84.5%, resp.) 100% usefulness in shortening encounter time & in increasing HCPs’ knowledge Both were rated highly for legibility and ease of understanding (88.7% vs. 90.3%)
    • 33. PhD Defense 33October 9, 2009 STUDY LIMITATIONS Few MDs and PAs participated (no NPs) Decliners were busy, in other projects or not interested Non-Intermountain HCPs were excluded Policies prohibited analysis of data outside of Intermountain network (non-covered entities) Marketing/recruitment policy restrictions Intermountain policies permitted only clinical managers at the clinics offering My Health services to recruit study reviewers –direct contact PI may be could have improved recruitment rates
    • 34. PhD Defense 34October 9, 2009 CONCLUSIONS The EMC and CoC report are useful vehicles for transporting patient healthcare information across the healthcare continuum and they can substantially enhance CoC. This was specifically demonstrated in Shortening patient-HCP encounter time Increasing the HCP overall knowledge Decision on prescriptions and on ordering new or repeating laboratory tests The reviewers’ perception of the usefulness of the EMC and CoC report in enhancing CoC was associated with age – further (larger) validation studies are needed
    • 35. PhD Defense 35October 9, 2009 ASSESSING PATIENT SATISFACTION WITH THE CONTINUITY OF CARE AND EFFECT OF PATIENT- ENTERED DATA ON THE QUALITY OF HEALTHCARE PROVIDER-MAINTAINED EMR DATA Olola CHO, Poynton M, Hales J, Narus S, Nebeker J, Rowan B, Smith M, Evans RS The International Journal for Quality in Health Care (Prepared for submission)
    • 36. PhD Defense 36October 9, 2009 STUDY OBJECTIVES To evaluate patient satisfaction with the usefulness of the emergency medical card (EMC) and CoC report in enhancing CoC Compared patient-entered data in the CoC report with the HCP-entered data in the EMR data to assess EMR data quality (i.e., accuracy and completeness)
    • 37. PhD Defense 37October 9, 2009 METHODS Patient satisfaction survey Promotional emails, meetings, “Teaser”, fliers, posters Excluded – never used EMC/CoC report (n=32) Complete online survey (with Likert Scale) (n=101; 76%) • Legibility, easy to use & understand • Encounter time, overall patient’s knowledge • Correct errors & complete missing data in the EMR • Overall quality of care Users of the CCR application to create EMC/CoC report (n=133)
    • 38. PhD Defense 38October 9, 2009 METHODS Evaluation of accuracy of HCP-entered data in EMR Instances of patient- entered data values (n=1,994) Study sample (n=1,505, 75.5%) Excluded – had no corresponding data fields in the EMR (n=489) Non-repeating records (e.g., address) Repeating records (e.g., labs, vitals) EMR data Summary of instances of accurate data values
    • 39. PhD Defense 39October 9, 2009 METHODS Evaluation of completeness of HCP-entered data in EMR Instances of all data values (8 months before use of CCR application) Summary of instances of complete data values Instances of all data values (8 months after use of CCR application) Instances of data values with non-blank/ missing values Instances of data values with non-blank/ missing values Compared only data fields that existed before and after use of CCR application
    • 40. PhD Defense 40October 9, 2009 RESULTS AND DISCUSSIONS Cumulative CCR application’s page views & actual use Promotional techniques significantly increased number of the application’s page views (n=22,024) and actual use (n=133) Strong correlation between page views and actual use (γ = 0.994, p=0.0005) Email messages to HCPs was best, then “Teaser” in My Health & lastly Fliers to HCPs
    • 41. PhD Defense 41October 9, 2009 RESULTS AND DISCUSSIONS Documents’ usefulness rating was significantly associated with patient’s age Majority created EMC for use in emergencies (56%) or for personal use (26%) Only about 15% of patients created CoC report for EMR updates Measurement Patients (N=101) n(%) Usefulness: n(%) EMC p† CoC report p† Sex Female 76(75.3) 41(54.0) 1.000 48(63.2) 0.232 Male 25(24.7) 13(52.0) 12(48.0) Age group (years) 20-30 12(11.9) 7(58.3) 9(75.0) 31-40 14(13.9) 10(71.4) 11(78.6) 41-50 22(21.8) 11(50.0) 0.019 10(45.5) 0.009 51-60 35(34.7) 12(34.3) 15(42.9) >60 18(17.8) 14(77.8) 15(83.3) Use of EMC and CoC report* To update records 16(9.4) To correct data errors 9(5.3) For personal use 44(25.9) Stored for emergency use 96(56.4) Reviewed and discarded 2(1.2) Others 3(1.8) Profile of responses *Data was collected in an Exit survey after patients created the documents
    • 42. PhD Defense 42October 9, 2009 RESULTS AND DISCUSSIONS Patients’ rating of the usefulness of EMC & CoC report EMC CoC report Overall pMeasure n usefulness n(%) Score Mean±SD n usefulness n(%) Score Mean±SD Data accuracy 99 71(71.7) 3.8±1.1 100 74(74.0) 3.8±1.0 0.882 Error correction 90 58(64.4) 3.8±1.0 92 62(67.4) 3.8±1.0 1.000 Completion of missing data 91 68(69.7) 3.9±1.0 94 70(74.5) 3.7±1.0 0.469 Document user-friendly 101 81(80.2) 4.0±0.9 101 84(83.2) 3.8±0.9 0.829 Confidentiality and security 101 84(83.2) 4.1±0.7 101 84(83.2) 4.1±0.7 0.829 Increased knowledge of condition 101 71(70.5) 3.8±1.1 100 69(67.0) 3.8±1.1 0.372 Enhanced quality of care 96 55(57.3) 3.7±1.0 95 59(62.1) 3.7±1.0 0.567 Increased trust with HCP 96 56(58.3) 3.7±1.0 95 55(57.9) 3.6±1.0 0.223 Improved relationship with HCP 95 53(55.8) 3.6±1.0 95 52(54.8) 3.6±1.0 0.203 Shorten encounter time 94 45(47.9) 3.5±1.0 94 42(44.7) 3.5±1.0 0.074 Lengthen encounter time 94 20(21.3) 2.9±1.0 93 23(24.7) 2.9±1.0 0.849 Overall 1,058 662(62.6) 1,060 674(63.6) 1,336(63.1) Overall, 63.1% of the patients found EMC and CoC report to be useful More patients for CoC than EMC (64% vs. 63%) , but no significant difference Agreement on the usefulness of EMC and CoC report was demonstrated in each CoC measure , but no significant difference in each measure’s ratings Patients rated documents highly for usefulness in shortening encounter time
    • 43. PhD Defense 43October 9, 2009 RESULTS AND DISCUSSIONS Patients-entered data vs. accuracy of EMR data 69% (70/101) of the patients entered new data values (n=1,994; 1,505 compared) 44% of new data was used for EMR update, but no significant difference (p=0.109) The majority of the EMR updates were for address, biodata, insurance, Primary HCP, labs Significantly low EMR updates observed in Biodata and primary HCP data No EMR updates for allergies & problems data Data category Data attributes Patient entries (n=1,994) EMR-updates p n Median(Q1,Q3)# n(%) Median(Q1,Q3)# Demographic Address 271 5(1,6) 241(88.9) 5(1,6) 0.085 Biodata¶ 555 9(8,9) 240(43.2) 3(3,4) <0.001 Insurance 115 2(1,2) 73(63.5) 1(1,2) - Primary HCP 121 2(2,2) 77(63.6) 1(1,2) <0.001 Clinical Allergies 106 5(3,5) 0(0.0) 0(0.0) - Problems 60 4(4,4) 0(0.0) 0(0.0) - Vital signs 63 6(3,7.5) 18(28.6) 2(2,4) 0.240 Appointments - - - - - Laboratory Observations & results 5 2.5(1,4) 4(80.0) 4(4,4) 1.000 Medication Prescription drugs 209 6(5,10) 6(2.9) 6(6,6) 0.790 Overall All data categories 1,505 2(2,6) 659(43.8) 2(1,4) 0.109 Q1/Q3: 25th & 75th Quartiles
    • 44. PhD Defense 44October 9, 2009 RESULTS AND DISCUSSIONS Patient-entered data vs. completeness of EMR data Category Data attributes Period n Complete data: n(%) OR(95%CI) p Demographic Address Before 3,153,789 2,867,118 (90.9) After 8,488,873 7,991,872(94.2) 1.61(1.60,1.62) <0.001 Biodata Before 24,462,684 23,883,032(97.6) After 7,319,910 5,943,165(81.2) 0.11(0.10,0.11) <0.001 Insurance Before 5,167,798 4,385,806(84.9) After 5,714,498 4,840,141(84.7) 0.99(0.98,0.99) <0.001 Primary HCP Before 773,742 773,742(100.00) After 843,481 843,481(100.0) - - Clinical Allergies Before 1,058,023 1,045,856(98.9) After 1,121,247 1,106,809(98.7) 0.89(0.87,0.91) <0.001 Problems Before 1,247,300 945,565(75.8) After 1,328,425 1,003,920(75.6) 0.99(0.98,0.99) <0.001 Vital signs Before 43,728,286 43,728,286(100.0) After 45,632,968 45,632,968(100.0) - - Appointments Before 20,922,920 20,608,315(98.5) After 16,199,284 15,985,094(98.7) 1.14(1.13,1.15) <0.001 Laboratory Observation & results Before 277,840,260 276,182,990(99.4) After 293,902,286 207,256,687(70.5) 0.01(0.01,0.01) <0.001 Medication Before 12,804,015 11,525,098(90.0) After 16,284,045 14,624,329(89.8) 0.99(0.98,0.98) <0.001 Inconsistency in associations shown between use of CCR application and data completeness Significant association between use of CCR application and improved data completeness was observed only in address and appointments data attributes Overall, 98.7% complete data before & 76.9% after (OR(95%CI: 0.780(0.779, 0.780), P<0.001)
    • 45. PhD Defense 45October 9, 2009 STUDY LIMITATIONS Some patient data were not extracted from EMR These were annotated by patients because the data was in free text format or not integrated in CDR Some sub-group analyses on EMR data quality did not yield results due to sample size issues E.g., Insurance, allergies and medical problems – but these may be because they accurately entered in EMR by HCPs Reason was not collected for data not updated in EMR Opportunity was missed of asking patients reasons why some entered data was not used to update EMR information
    • 46. PhD Defense 46October 9, 2009 CONCLUSIONS Patients demonstrated that the EMC and CoC report were useful tools in enhancing CoC Patients also showed that the two documents were useful to identify missing patient information especially in the demographic and appointment categories than other categories The patient is an important source of quality control for their record in HCP-maintained EMR
    • 47. PhD Defense 47October 9, 2009 PRESENTATION OUTLINE Introduction Background Project implementation Project evaluation Conclusions
    • 48. PhD Defense 48October 9, 2009 RESEARCH CONCLUSIONS Contribution to the field of Biomedical Informatics Showed that the CCR standard can be used to ensure that patient information that is shared among HCPs is standardized Demonstrated that HCP-verified EMR data can be used to create EMCs (and CoC reports), in addition to the prevalent use of patient- entered data Showed that patients are able to access their PHRs, monitor and control the quality of their information in the HCP-entered data in EMR Showed that timely and accurate patient information can be availed to foster enhanced efficiency and effectiveness in the EMR updates and medical decision making by HCPs
    • 49. PhD Defense 49October 9, 2009 RESEARCH CONCLUSIONS Lessons Learned and Future Direction Free-text, non-integrated data sources and lack of full interoperability of EMRS still pose data extraction difficulties Patient is an important source of quality control for their records in HCP-entered data in the EMR The EMC and CoC report should be kept up to date since both HCPs and patients have shown the usefulness of the two documents in enhancing CoC – more patients printed EMC Use of a variety of promotional techniques are useful for improved (wide scope) marketing and recruitment Further validation studies are recommended
    • 50. PhD Defense 50October 9, 2009 ACKNOWLEDGMENTS INSTITUTIONAL REVIEW BOARDS (IRBS) University of Utah IRB Intermountain Healthcare IRB NIH/NLM/MICHIGAN STATE UNIVERSITY Julia Royall Terrie Taylor DBMI Reed Gardner, Joyce Mitchell, Lynn Ford, John Hurdle Matt Samore, Adi, Lisa-Canon Albright Kathy Stoker, Linda Galbreath, JoAnn Thompson Faculty, staff and fellow students ITS/EDW TEAM Jim Livingston, Cheri Hunter, Ming Tu and Vick Deshmukh NATIONAL ACADEMY OF EMERGENCY DISPATCH Jeff Clawson, Alan Fletcher, Pam Stewart INTERMOUNTAIN HEALTHCARE PHC team: Belle Rowan (Chair), Matt Smith, Traci Hastings, Carol Askew, Chris Nuccitelli Len Bowes, Stan Huff ISSA, EDW, SelectHealth… UOU/DBMI COMMITTEE R Scott Evans (Chair) Mollie Poynton Scott Narus Jonathan Nebeker Joe Hales MY FAMILY Mom, Dad, and my Wife and Children

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