1
Harnessing Electronic Health Records
and Health Information Technology to
Achieve Population Health
Jonathan P. Weiner, ...
2
The digitalization of medical care delivery
is at a tipping point
Source: USDHHS, CDC-National Center for Health Statist...
THE OPPORTUNITIES FOR IMPROVING THE
HEALTH OF POPULATIONS WILL BE PROFOUND:
• Using EHRs linked to smart phones, a medical...
4
In this presentation I will discuss:
• Trends and frameworks related to electronic
health records (EHRs), “e-health” and...
5
Medical Care / Clinical
Sciences
Health
Informatics /
HIT
Population /
Public Health
Sciences1
Population Health IT: Dis...
6
A few working definitions:
Healthcare Information Technology (HIT) - The application of
electronic health records (EHRs)...
Healthcare Analytics - the leveraging of electronically
available healthcare data to enable actions that improve
health sy...
CDC’s estimates of impact of each determinant on mortality and morbidity.
Social Determinants, Environment and Behaviors
a...
The e-health / HIT framework that will soon define
the “digital health care milieu”
Physician Patient
Practice Family
Team...
Applying HIT to achieve care
that is:
- Population focused
- High value, and
- Integrated
HIT and population health is core to the
Patient Centered Medical Home (PCMH)
Integrate
E-prescribing
And
COES
EHR/HIE
Con...
12
Source: Premier Healthcare Alliance
HIT is core to the Accountable Care
Organization (ACO)
13
Transforming Health Care Will Require
Paradigm Shifts and HIT Support
TRANSFORMEDCURRENT
Coordinated /Integrated CareFr...
14
Key applications of HIT for “population health
decision support” within integrated delivery
systems
• Risk identificati...
Population Health Informatics at Johns
Hopkins (JHHC)
Inputs
Outputs
Case Manager Medical Directors
Clinical
Management Te...
Using Predictive Models to Identify Patients at Risk for
Future Hospitalization:
Our Johns Hopkins ACG “PM” system is used...
•
Source: CMS Innovation Planning Grant Received by the Maryland DHMH
Hot-Spotting Baltimore Hospitalizations Using HIE Da...
Johns Hopkins CMS Innovation Grant – Community Health Partnership
Grant Targeting Population in East Baltimore
Characteris...
Pop HIT Challenges: We need
• To find ways to integrate disparate “numerators” &
“denominators” to define true populations...
Population Health IT Challenges - 2
• Standards and frameworks for integrating across
EHR / IT vendors to achieve true com...
The Johns Hopkins Center for Population
Health IT (CPHIT) -- Mission and Focus
The mission of CPHIT (“see-fit”) is to impr...
1. Development and testing of health status and quality
measures created from EHRs and other HIT systems.
2. Use and advan...
Scope of CPHIT’s Activities
• Establish a leadership role in the development of a
national/global research agenda for popu...
24
Challenges, Opportunities Future
Directions
Further Information
Center Director
Prof. Jonathan Weiner, DrPH
jweiner@jhsph.edu, 410 955-5661
The Johns Hopkins Center f...
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iHT² Health IT Summit New York - Presentation “Harnessing EHRs and Health IT to Achieve Population Health”

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Presentation “Harnessing EHRs and Health IT to Achieve Population Health”

Jonathan Weiner, DrPH
Professor Department of Health Policy and Management
Director of Center for Population Health IT
Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland

Professor Weiner’s presentation will focus on how electronic health records and other e-health tools can be harnessed to move beyond providing medical care for a single patient episode towards the achievement of “population health.” This provocative presentation will offer new conceptual paradigms and will review “big data” opportunities and challenges. The emphasis of the talk will be on how population focused care transformation can be brought about through the integration and application of e-health/EHR systems and claims/MIS systems. The talk will offer examples of analytic tools and methods designed to increase the effectiveness, efficiency and equity of care provided at a geographic community level and to “populations” of consumers enrolled in health plans, ACOs and other integrated delivery systems.

Key goals of presentation:

∙ To offer frameworks and paradigms to better understand how EHRs and other HIT can improve population health
∙ To outline opportunities and challenges for communities, ACOs and other integrated delivery systems
∙ To offer some case studies on the application of health IT to population health

Published in: Education, Health & Medicine
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iHT² Health IT Summit New York - Presentation “Harnessing EHRs and Health IT to Achieve Population Health”

  1. 1. 1 Harnessing Electronic Health Records and Health Information Technology to Achieve Population Health Jonathan P. Weiner, DrPH Professor of Health Policy & Management and of Health Informatics, Director of the Center for Population Health IT (CPHIT) The Johns Hopkins University, Baltimore Maryland, USA Jweiner@jhsph.edu, www.jhsph.edu/cphit Presented at the Institute for Health Technology Transformation (IHT2) – NYC, NY. September 18, 2013
  2. 2. 2 The digitalization of medical care delivery is at a tipping point Source: USDHHS, CDC-National Center for Health Statistics - 2013
  3. 3. THE OPPORTUNITIES FOR IMPROVING THE HEALTH OF POPULATIONS WILL BE PROFOUND: • Using EHRs linked to smart phones, a medical director could identify, monitor and improve the care of tens of thousands of persons with chronic diseases living in her community. • A scientist could evaluate the community health impacts (and cost) of a new medical intervention in near real time. • Social services, environmental health and medical care data could be fully integrated in real time to maximize health for targeted special populations in a geographic catchment area. • Consumers, doctors, public health officers and nurse outreach workers could all share real time information and clinical guidance in the event of a disease outbreak. • Based on public health analyses, an entire health delivery system could modify its standards of care within a few weeks of a major new scientific discovery. 3
  4. 4. 4 In this presentation I will discuss: • Trends and frameworks related to electronic health records (EHRs), “e-health” and health IT (HIT) of special relevance to populations, communities and other target “denominators.” • The potential for HIT to improve the:  health of populations and  the effectiveness and efficiency of integrated health care delivery systems.
  5. 5. 5 Medical Care / Clinical Sciences Health Informatics / HIT Population / Public Health Sciences1 Population Health IT: Disciplines and Examples Population HIT Examples: 1. Assessing community health status & need 2. Public health surveillance 3. Improving performance for populations served by integrated delivery system 4. Population decision support for prevention / chronic care management 5. Consumer e-health in support of wellness/ care management 5 34 2
  6. 6. 6 A few working definitions: Healthcare Information Technology (HIT) - The application of electronic health records (EHRs) and other digital technologies to the delivery and management of health care. “Interoperable” EHRs represent the backbone of a national healthcare information infrastructure. Health Informatics - The systematic application of information and computer sciences and technology to health care practice, research, and learning. E-health - Health and health care practices supported by electronic processes and communication. The term is inconsistently used: some use it interchangeably with HIT. Others use it more narrowly as consumer targeted health and health care support delivered or enhanced through the internet or mobile (“m-health”) devices.
  7. 7. Healthcare Analytics - the leveraging of electronically available healthcare data to enable actions that improve health system effectiveness, efficiency or equity. Population Health- A comprehensive framework for assessing and improving the health and well being of a defined population. Population health is practiced by private and public organizations that focus on communities, persons “enrolled” by a health care organization, or other groupings of individuals that comprise a specific cohort of interest. Public Health - Societal (i.e., government) actions to improve health. The core public health functions relate to assessment, assurance and policy setting. 7 Working definitions – Cont.
  8. 8. CDC’s estimates of impact of each determinant on mortality and morbidity. Social Determinants, Environment and Behaviors are Key to Achieving “Population Health” 8
  9. 9. The e-health / HIT framework that will soon define the “digital health care milieu” Physician Patient Practice Family Team EHRs Web-Portals M-health Apps PHRs e-mail / internet/ Social networks Secure Messaging ICT / wireless & wired Biometric/ Telemed CDS / POE ACO= Accountable Care Organization EHR = electronic health record PHR = personal health record CDS = clinical decision support IT systems MIS/HIS = Management/Health IT systems POE = provider order entry IT systems Claims/ MIS/ HIS PH/ HR IT PH/HR = public health / human resource IT systems Telemed = telemedicine/ remote patient monitoring-M-health = mobile health applications ICT = information / communication technology Source: Weiner, 2012 http://www.ijhpr.org/content/1/1/33
  10. 10. Applying HIT to achieve care that is: - Population focused - High value, and - Integrated
  11. 11. HIT and population health is core to the Patient Centered Medical Home (PCMH) Integrate E-prescribing And COES EHR/HIE Connected Public Health Bio Surveillance Connected Two way Quality Reporting Electronic Eligibility System Interface Electronic Patient Access and Communication E-Clinical Decision Support Patient Registry Databases Advance Chronic Disease Mgmt Medical Home 2.0 11 Source: US Medicare (CMS) Innovation Center
  12. 12. 12 Source: Premier Healthcare Alliance HIT is core to the Accountable Care Organization (ACO)
  13. 13. 13 Transforming Health Care Will Require Paradigm Shifts and HIT Support TRANSFORMEDCURRENT Coordinated /Integrated CareFragmented Care Patient / Population FocusedProvider Centric Payment for Value / OutcomePayment for Volume / Units Care System FocusedIndividual Facility Focused Care Team AccountabilityPhysician Accountability TransparencyOpaque rules and systems Wellness / Chronic co-morbiditiesDisease oriented / Acute Illness Evidence-Based Care /Learning Organiz.Limited Basis for Clinical Action See: Weiner –Executive Insight Magazine Nov 2011,: http://healthcare-executive-insight.advanceweb.com/Archives/Article-Archives/Virtual-Glue-for-a-Transformed-Healthcare-System.aspx
  14. 14. 14 Key applications of HIT for “population health decision support” within integrated delivery systems • Risk identification / stratification for targeting priority populations/patients • Provider focused process improvement focusing on patient “denominators” • Patient / consumer targeted care management and wellness using “e- health” / “m-health” tools • High level monitoring of outcomes/value of the entire target population
  15. 15. Population Health Informatics at Johns Hopkins (JHHC) Inputs Outputs Case Manager Medical Directors Clinical Management Team Patient Care Reports Provider Profile ACG Risk Measures: Scientific Knowledge: clinical guidelines Clinical / EHR/ Lab Results Claims, Rx, Enrollment, Self-reported Health Risk Data Population Statistics Population Groups Users Informatics Update Monthly Review Annually Update Monthly Update Monthly Claims/Operations Tables Lab Results Tables ACG Tables Scientific Tables Update monitored patient and clinical events tables Monitored Patient Tables Clinical Events Tables Create Reports Routinely and on Demand 15
  16. 16. Using Predictive Models to Identify Patients at Risk for Future Hospitalization: Our Johns Hopkins ACG “PM” system is used in 18 nations 1.6% 1.2% 3.0% 94% 6% Distribution of JHU ACG "Probability of Hospitalization" PM Risk Score .3 to <= 1.0 .2 to < .3 .1 to < .2 .0 to < .1 0% 20% 40% 60% 80% 100% .0to<.1 .1to<.2 .2to<.3 .3to<.4 .4to<.5 .5to<.6 .6to<.7 .7to<.8 .8to<.9 .9to… 2% 28% 47% 59% 78% 100% Percent Actually Hospitalized by ACG Predictive Model Risk Score Scores Based on ACG Version 9.0 Hospitalization Prediction Risk Model - This is for a Medicaid Cohort enrolled in private health plans. (See: www.acg.jhsph.edu)
  17. 17. • Source: CMS Innovation Planning Grant Received by the Maryland DHMH Hot-Spotting Baltimore Hospitalizations Using HIE Data
  18. 18. Johns Hopkins CMS Innovation Grant – Community Health Partnership Grant Targeting Population in East Baltimore Characteristics of high-risk group: • 36% have 6+ chronic conditions. • 47% have 1 or more hospital admissions during Nov 2011- Oct 2012 • 1,117 total admissions (76% all admissions) • Total cost of care is $30 Million • Average of $29,679 per person per year Characteristics low/ moderate risk Group: • 6% have one admission • Total cost of care is $29 Million • Average of $5,463 per person per year High Complexity 1000 people at six clinics Moderate and Low Complexity 5,258 people at six clinics JHU ACG Risk Score Using JH EMR/HIT 18
  19. 19. Pop HIT Challenges: We need • To find ways to integrate disparate “numerators” & “denominators” to define true populations and communities. • Models and tools to help medical care systems move towards population perspectives. • Computer science / informatics technical tools that facilitate public health and population health operational needs. To date main focus has been on clinical and administrative issues. • Advanced tools for extracting and analyzing unstructured data. 19
  20. 20. Population Health IT Challenges - 2 • Standards and frameworks for integrating across EHR / IT vendors to achieve true community standards in this domain. • New policy/legal frameworks and financial structures that support population focus. • Closer collaboration between government, providers, payers/regulators, IT industry and academia. • Viable models for supporting ongoing development and dissemination of evidence and tools in the population health IT area. 20
  21. 21. The Johns Hopkins Center for Population Health IT (CPHIT) -- Mission and Focus The mission of CPHIT (“see-fit”) is to improve the health and well-being of populations by advancing the state-of- the-art of Health Information Technology (HIT) and e- health tools used by private health care organizations and public health agencies. CPHIT’s focus will be on the application of electronic health records (EHRs), e-health and other digitally-supported health improvement interventions targeted at communities, special need populations and groups of consumers cared for by integrated delivery systems (IDSs). 21
  22. 22. 1. Development and testing of health status and quality measures created from EHRs and other HIT systems. 2. Use and advancement of computing methodologies – including natural language processing (NLP) and pattern recognition tools. 3. Initiation of effective approaches for linking provider- centric EHR systems with consumer-centric internet and mobile-based e-health applications. 4. Development of EHR-based tools and decision support applications to help manage high risk populations. 22 Some Key priorities of JHU CPHIT R&D Center
  23. 23. Scope of CPHIT’s Activities • Establish a leadership role in the development of a national/global research agenda for population HIT. • Undertake breakthrough and translational R&D and associated technology transfer. • Establish a comprehensive R&D infrastructure with access to EHR data and a large cadre of multi- disciplinary Johns Hopkins University (JHU) faculty. • “Industry Partners” program to initiate and maintain active collaboration with industry stakeholders. • Further the education of the next generation of population health informatics specialists. 23
  24. 24. 24 Challenges, Opportunities Future Directions
  25. 25. Further Information Center Director Prof. Jonathan Weiner, DrPH jweiner@jhsph.edu, 410 955-5661 The Johns Hopkins Center for Population Health Information Technology (CPHIT) 25 www.jhsph.edu/cphit

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