Anda di halaman 1dari 112

SHRS-P 664 Administration and Management of Physical Therapy Services

Using Health Information Technology


How it might save lives but steal your sunshine

Daniel J. Vreeman, PT, DPT, MS, FACMI


Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards


@djvreeman Regenstrief Center for Biomedical Informatics

© 2018 © 2018
For as long as I have wanted to
be a clinician, I have also loved
science and computers.
No Magical
Thinking!

📷 jdhancock | cc-by
Biomedical informatics (BMI)
The interdisciplinary field that studies and
pursues the effective uses of biomedical
data, information, and knowledge for
scientific inquiry, problem solving and
decision making, motivated by efforts to
improve human health.

https://www.amia.org/biomedical-informatics-core-competencies
Human 

+

Computer
! Human

Friedman CP. A "fundamental theorem" of biomedical informatics. J Am Med Inform Assoc. 2009 Mar-Apr;16(2):169-70.PubMed PMID: 19074294;
Objectives
When it’s all said and done, you’ll be able to…

1. Explain the current forces driving adoption of information technology in


healthcare
2. Appreciate the kinds of problems that can be improved with more judicious use
of health information technology
3. Discuss the key factors for success, as well as important barriers to
implementing electronic health record systems in rehabilitation
4. Articulate at least one way that you could use health information technology to
improve care

photo via Verino77


First, some
introductions…
48
mins/day
mean time loss per clinic day for attending physicians

The EHR steals 60 minutes a day from me!


McDonald CJ, Callaghan FM, Weissman A, Goodwin RM, Mundkur M, Kuhn T. Use of internist's free time by ambulatory care Electronic Medical Record systems. JAMA
📷 lara604 | cc-by
Intern Med. 2014 Nov;174(11):1860-3. PMID: 25200944.
4x
improvement of overdue clinical tasks!
(68% vs 18%)

Were MC, Nyandiko WM, Huang KT, et al. Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting. Pediatrics. 2013 Mar;
131(3):e789-96. Epub 2013 Feb 25. PubMed PMID: 23439898.
Saving lives or
stealing sunshine?
The Future
Great Scott!

📷 jdhancock | cc-by
Complete, longitudinal information
that follows the consumer
Care that is coordinated
across settings, disciplines,
geography, etc
Health decisions for individuals made
with information tools that assist and
guide, accounting for everything from
molecules to the environment

📷 glasgowamateur | cc-by-sa
This system has
way more than just electronic
versions of paper records.
How can Health IT help?
Inform shared clinical decision making

Incorporate diverse data into diagnosis, predictions, and CDSS

Integrate care pathways into clinical workflow

Expand health system’s ability to tailor to its population needs

Provide a rich platform for discovery

Adler NE, Stead WW. Patients in context--EHR capture of social and behavioral determinants of health. N Engl J Med. 2015 Feb 19;372(8):698-701. doi: 10.1056/NEJMp1413945. PubMed PMID: 25693009.

Hossein Estiri, Chirag J Patel, Shawn N Murphy; Informatics can help providers incorporate context into care, JAMIA Open, Volume 1, Issue 1, 1 July 2018, Pages 3–6, https://doi.org/10.1093/jamiaopen/ooy025
What might it enable?
More effective and personalized care
More effective population management
Discover new insights

📷 proimos | cc-by-nc
" Meanwhile,
back on planet Earth…
Reality:
patients move faster and further
than their health information
Connecting Many Data Sources

Social and community determinants


Lifestyle and behavioral
Health history
Patient-generated
EHR/clinical
Genetics
Basic science
Variation abounds…
CODE NAME
34626D Arterial BP Diastolic
39312D ABP Diastolic
ARTDIASBP Arterial Diastolic BP
nvArtBPS Arterial Blood Pressure Diastolic
DBP DBP
25284D BP (NIBP)
2737317 Diastolic Blood Pressure #1
6881D BP Diastolic
3800DBP BP
77934D BP Manual Diastolic
919109 Diastolic Blood Pressure
DiastBP DiastolicBP
PBPD PRE BLOOD PRESSURE DIASTOLIC
POBPD POST BLOOD PRESSURE DIASTOLIC
It's like, the
data
more money we
come across,

the more
problems we see
Taming the “wicked”
interoperability problem
We need two different kinds of standards

📷 tgerus | cc-by-sa
Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR

Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, CPT, ICD
meerkat meerkat mere cat meerkat

Similar name. Different Meaning.

📷 CaptionTime
Vreeman DJ, Richoz C. Possibilities and Implications of Using the ICF and Other Vocabulary Standards in Electronic Health Records. Physiother Res Int. 2013 Jul 30; PMID: 23897840
Health IT in the U.S.
Macro View
Resolved, That the American Physical Therapy
Association supports the use of electronic
health record systems (EHRs) and promotes the
widespread adoption of interoperable EHRs in
all physical therapy practice settings.
Many forces converging on the need for
interoperable EHRs

21st Century Cures with TEFCA/USCDI (and ISA)


“Promoting Interoperability” and related programs ( superseding “Meaningful Use”)
Value-based healthcare
Precision medicine
Population health
Care coordination
Quality measurement
Person-centered care
Innovation
https://qpp.cms.gov

CMS has proposed, as part of the 2019


physician fee schedule, to require many
PTs in private practice to participate in
the QPP program through either MIPS or
advanced APMs beginning January 2019.
Additionally, CMS has proposed to allow
certain other PTs and physical therapy
practices to opt into the program,
enabling them to earn incentive payments
and to prepare for participation in APMs.
Provisions for certification that
information be “accessed, exchanged and
used without special effort” through
technologies such as open application
programming interfaces (API).
Almost 87% of hospitals and
57% of MIPS eligible clinicians
are served by health IT
developers with product(s)
certified to FHIR release 2
https://www.healthit.gov/buzz-blog/interoperability/heat-wave-the-u-s-is-poised-to-catch-fhir-in-2019/
https://www.healthit.gov/buzz-blog/interoperability/heat-wave-the-u-s-is-poised-to-catch-fhir-in-2019/
https://www.apple.com/healthcare/health-records/

https://support.apple.com/en-us/HT208647
4 Ways Health IT can Accelerate
that Vision of the Future
Seamless web of data
Data reuse
Data analytics
Clinical decision support
Creating a seamless
web of data
The rain forest canopy is a seamless web
through which arboreal creatures efficiently
move to reach the edible fruits without any
attention to the individual trees.

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
http://www.ihie.org/careweb/
Creating a unified patient record

http://www.ihie.org/careweb/
41%
of ED visits are for patients with data at
another institution

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.
Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.
Nearly every ED in
Indiana shares patients
with every other ED in
the state
Collect once. Use many.
Clinical care, public health reporting, quality management, clinical and
epidemiological research, etc…

📷 pagedooley | cc-by
75856-5
#Falls in past 1Y

66247-8
Sit to stand [30 sec]

8454-1
DBP - standing

8460-8
SBP - standing
If this, then that…

If {# Falls in last year} > 0

Then
initiate {gait, strength, balance evaluation}
Reporting / Analytics
% patients 65 years of age and older who were screened for future fall risk

75856-5 Number of falls in the past 12 months [Reported]

59460-6 Fall risk total [Morse Fall Scale]

66247-8 Sit to stand 30 seconds

52552-7 Falls in the past year [CMS Assessment]

83280-8 Has the patient had any falls since admission [CMS Assessment]

71949-2 Falls Behavioral Scale for Older People [FaB]


Same data for…
Informing clinical care
Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
http://www.ptoutcomes.com
http://www.ptoutcomes.com
Data Analytics
“What Does $67B Dell Deal Mean for Healthcare Big Data Analytics?”

“Blue Cross CIO: Big Data Can Fix Healthcare Quality, Costs”

“Experts Say ‘Big Data’ Represents Future of Health Care Research”

“Healthcare Big Data Analytics Keeps Small Hospitals Independent”

“North America to Lead the Global Healthcare Analytics Market”

“Global Big Data Spending in Healthcare Industry to Grow at a CAGR of 42% Over the Period
2014-2019”
📷 duncan | cc-by-nc
A deep learning approach that incorporated the entire
electronic health record, including free-text notes,
produced predictions for a wide range of clinical problems
and outcomes that outperformed state-of-the-art traditional
predictive models. Because we were interested in
understanding whether deep learning could scale to produce
valid predictions across divergent healthcare domains, we
used a single data structure to make predictions for an
important clinical outcome (death), a standard measure of
quality of care (readmissions), a measure of resource
utilization (length of stay), and a measure of understanding
of a patient’s problems (diagnoses).

Rajkomar A, Oren E, Chen K, et al. Scalable and accurate deep learning with electronic health records. npj Digital Medicine 2018;1:18. doi:10.1038/s41746-018-0029-1
Rajkomar A, Oren E, Chen K, et al. Scalable and accurate deep learning with electronic health records. npj Digital Medicine 2018;1:18. doi:10.1038/s41746-018-0029-1
Population health analytics

Tchalla AE, Dufour AB, Travison TG, Habtemariam D, Iloputaife I, Manor B, et al. (2014) Patterns, Predictors, and Outcomes of Falls Trajectories in Older Adults: The
MOBILIZE Boston Study with 5 Years of Follow-Up. PLoS ONE 9(9): e106363. https://doi.org/10.1371/journal.pone.0106363
Clinical Decision Making
Right info. Right time. Right format.
Evidence-based Practice
patients + evidence + clinical expertise

Everyone wants it.


Nobody has time.
(So they say)

Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
How can EHRs help?
Tools to implement EBP at the point of care.
EHR Decision Support
A computer-generated suggestion about care for an
individual patient
The secret sauce of
the EHR chicken soup

photo via liber


📷 liber | cc-by
📷 duncan | cc-by-nc
Not too bad!
Just for fun…
Back to EHRs…
Limit to reviews (n=2453)
Holt TA, Thorogood M, Griffiths F. Changing clinical practice through patient specific reminders available at the time of the clinical encounter: systematic review and
meta-analysis. J Gen Intern Med. 2012 Aug;27(8):974-84.PubMed PMID: 22407585; PubMed Central PMCID: PMC3403145.
Odds Ratio = 1.79
95% CI 1.56, 2.05

Holt TA, Thorogood M, Griffiths F. Changing clinical practice through patient specific reminders available at the time of the clinical encounter: systematic review and
meta-analysis. J Gen Intern Med. 2012 Aug;27(8):974-84.PubMed PMID: 22407585; PubMed Central PMCID: PMC3403145.
https://www.youtube.com/user/thehealthcaretriage/
Your Turn
If this, then that…
If this, then that…

If {Hgb < 8 gm/dL}

Then
Prompt: “No exercise. Essential daily activities
only.”
Give it your best shot
Is there any Health IT
evidence in Rehabilitation?
1968!

Vallbona C, Spencer WA, Levy AH, Baker RL, Liss DM, Pope SB. An on-line computer system for a rehabilitation hospital. Methods Inf Med. 1968 Jan;7(1):31-9. PubMed PMID: 5666543.
This review suggests that
EHRs have potential benefits
for physical therapists.

Vreeman DJ, Taggard SL, Rhine MD, Worrell TW. Evidence for electronic health record systems in physical therapy. Phys Ther. 2006 Mar;86(3):434-46; discussion 446-9. Review. PubMed PMID: 16506879.
Benefits of EHRs
Improved reporting
Improved operational efficiency
Improved communication
Improved data accuracy
Vreeman DJ, Taggard SL, Rhine MD, Worrell TW. Evidence for electronic health record systems in physical therapy. Phys Ther. 2006 Mar;86(3):434-46; discussion 446-9. Review. PubMed PMID: 16506879.
Barriers to Implementing
Behavior or workflow modification
Software/hardware inadequacy
Staff training

Vreeman DJ, Taggard SL, Rhine MD, Worrell TW. Evidence for electronic health record systems in physical therapy. Phys Ther. 2006 Mar;86(3):434-46; discussion 446-9. Review. PubMed PMID: 16506879.
Factors for Success
End-user participation i n development
Data standardization
Adequate staff training
Incorporating workflow analysis
Vreeman DJ, Taggard SL, Rhine MD, Worrell TW. Evidence for electronic health record systems in physical therapy. Phys Ther. 2006 Mar;86(3):434-46; discussion 446-9. Review. PubMed PMID: 16506879.
Most common
complaint?
anecdotal
Implementing a fall prevention program
that adheres to clinical guidelines,
however, requires addressing the
significant logistical barriers that
impede the integration of fall prevention
activities into primary care.

Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
…tailor the reminder to existing clinic
setups and workflows.

Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
My Summary:
Reminders can help, but healthcare is
complex (because it involves people)!

Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
The main finding is that inactive individuals,
as well as overweight children and adults, and
patients with chronic diseases such as
diabetes, have been found to gain benefit of
using physical activity interventions with CDS
resulting in increased physical activity,
weight loss, or improved health.

Triantafyllidis A, Filos D, Claes J, et al. Computerised decision support in physical activity interventions: A systematic literature review. Int J Med Inform 2018;111:7–16. doi:10.1016/j.ijmedinf.2017.12.012
…integration of CDS systems in physical
rehabilitation with clinical information
systems such as electronic health records
would be of great value, because of their
ability to provide on a regular basis
important, personalised clinical information,
reinforcing the potential to identify robust
ways for the optimal management of patient’s
physical activity in everyday life.

Triantafyllidis A, Filos D, Claes J, et al. Computerised decision support in physical activity interventions: A systematic literature review. Int J Med Inform 2018;111:7–16. doi:10.1016/j.ijmedinf.2017.12.012
The aim of this study was to describe the
process by which a group of subject
matter experts in the area of return to
work developed a resource tool to provide
clinical decision support (CDS) for
primary care clinicians.

McLellan RK, Haas NS, Kownacki RP, Pransky GS, Talmage JB, Dreger M. Using Electronic Health Records and Clinical Decision Support to Provide Return-to-Work Guidance for Primary Care Practitioners for Patients With
Low Back Pain. J Occup Environ Med. 2017 Nov;59(11):e240-e244. Review. PubMed PMID: 29023338; PubMed Central PMCID: PMC5957077.
McLellan RK, Haas NS, Kownacki RP, Pransky GS, Talmage JB, Dreger M. Using Electronic Health Records and Clinical Decision Support to Provide Return-to-Work Guidance for Primary Care Practitioners for Patients With
Low Back Pain. J Occup Environ Med. 2017 Nov;59(11):e240-e244. Review. PubMed PMID: 29023338; PubMed Central PMCID: PMC5957077.
If this, then that…
If {acute LBP w or w/o leg pain} &&
NO {red flags*} &&
{functional limitations} &&
{patient requests or requires an activity note or
instructions about activity}
Then
Discuss {how limitations affect work and activities} &&
Write {activity prescription} &&
Provide {increasing activity educational handout} &&
Transmit {activity prescription} upon request &&

Red flags include potentially serious disorders: acute fractures, acute dislocations, infection, tumor, progressive neurologic deficit, or cauda equina syndrome
The CDS tool does not require the PCP to
collect occupational health data before
generating the activity prescription
because job demand information is not
likely to be present in the chart and
collecting occupational data adds to the
provider’s burden.

McLellan RK, Haas NS, Kownacki RP, Pransky GS, Talmage JB, Dreger M. Using Electronic Health Records and Clinical Decision Support to Provide Return-to-Work Guidance for Primary Care Practitioners for Patients With
Low Back Pain. J Occup Environ Med. 2017 Nov;59(11):e240-e244. Review. PubMed PMID: 29023338; PubMed Central PMCID: PMC5957077.
Getting from here…

to there.
📷 janeandd | cc-by
Embrace Health IT as an
essential tool for you as a
clinician.

and manager, population health specialist, researcher, etc…

Be mindful of the complexity.


Physical therapist education
programs should incorporate
core informatics competencies
into their curricula.

Wilkinson SG, Chevan J, Vreeman DJ. Establishing the Centrality of Health Informatics in Physical Therapist Education: If Not Now, When? Journal of Physical Therapy Education 2010;24:10–5.
Although most health
professionals use IT daily in
their work, few know how to
adapt their roles and work
processes to incorporate IT
for the greatest benefit.

Stead WW, Searle JR, Fessler HE, Smith JW, Shortliffe EH. Biomedical informatics: changing what physicians need to know and how they learn. Acad Med. 2011 Apr;86(4):429-34. PMID: 20711055
We have frequently heard the opinion from
both faculty and students that medical
students already possess all the basic
skills necessary to function effectively
in an information-rich environment.

This is similar to assuming that a


student proficient in the use of a word
processing program knows how to write an
award-winning novel.
Silverman H, Cohen T, Fridsma D. The evolution of a novel biomedical informatics curriculum for medical students. Acad Med. 2012 Jan;87(1):84-90. PubMed PMID: 22104049
If this crazy informatics
geekery sounds like fun,
there’s a potential career path
for you to specialize.
Key Lessons
for Today
📷 IMLS DCC | cc-by
Human 

+

Computer
! Human

Friedman CP. A "fundamental theorem" of biomedical informatics. J Am Med Inform Assoc. 2009 Mar-Apr;16(2):169-70.PubMed PMID: 19074294;
Interoperable Health IT can
improve clinical decisions and
support data re-use
(for lots of purposes)
Closing Thought
Tone is in your fingers
Though Wooten's basses receive
much attention, his most
frequent and consistent
response when asked by his
fans about his equipment is
that "the instrument doesn't
make the music ... you do".
📷 scragz | cc-by
Q & A