1. Are EHR’s enough for population health? Lisa Dolan-Branton Indian Health Service AHRQ Annual Conference Sept 15, 2007

2. Objectives Indian Health Service HIT Strategic Priorities Population Health What matters

3. Who are We? A comprehensive health service delivery system for approximately 1.9 million of 3.3 million American Indians and Alaska Natives from 562 federally recognized tribes in 35 statesA comprehensive health service delivery system for approximately 1.9 million of 3.3 million American Indians and Alaska Natives from 562 federally recognized tribes in 35 states FY 2009 spend authority is over 4 billion.FY 2009 spend authority is over 4 billion. Indian Health Service total staff consists of about 15,600 employees, which includes approximately 2,500 nurses, 1600 CHRs, 900 physicians, 500 pharmacists, and 300 dentistsIndian Health Service total staff consists of about 15,600 employees, which includes approximately 2,500 nurses, 1600 CHRs, 900 physicians, 500 pharmacists, and 300 dentists

4. The IHS Mission, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

6. AI/AN Rate 2002- 2004 ALL CAUSES 1027.2 832.71.2 Tuberculosis1.7 0.28.5 Diabetes74.225.32.9 Unintentional Injuries 94.8 37.3 2.5 Suicide17.910.81.7 Cervical cancer4.7 2.51.9 Infant deaths 1/ 11.7 6.91.7 Pneumonia/Influenza32.322.01.5 1/ Infant deaths per 1,000 live births US All Races Rate 2003 Ratio: AI/AN to US All Races MORTALITY RATE DISPARITIES

7. A Broader Picture of Health  Personal Health  Family Health  Community Health  Public Health  Population Health  Transparency of Data  Patient and community sharing of information  Commitment to Health Equity

8. IHS Strategic Priorities Build and sustain healthy communities Provide accessible, quality healthcare Foster collaboration and innovation across the Indian Health network IHS Strategic Priorities are supported by technology initiatives, not driven by them.

9. Care Model for the Indian Health System Improved health and wellness for American Indian and Alaska Native individuals, families, and communities Delivery System Design Decision Support Clinical Information Systems Self- Management Support Community Health Care Organization Activated Family and Community Informed Activated Patient Prepared Proactive Care Team Prepared, Proactive Community Partners EFFECTIVE RELATIONSHIPS Efficient Safe Effective Equitable Timely Patient-Centered

10. Care Model for the Indian Health System Improved health and wellness for American Indian and Alaska Native individuals, families, and communities Delivery System Design Decision Support Clinical Information Systems Self- Management Support Community Health Care Organization Activated Family and Community Informed Activated Patient Prepared Proactive Care Team Prepared, Proactive Community Partners EFFECTIVE RELATIONSHIPS Efficient Safe Effective Equitable Timely Patient-Centered Use data at the point of care Facilitate individual patient care planning Identify relevant subpopulations for proactive care Provide timely automated reminders for providers and patients Share information with patients Allow staff to coordinate care Monitor performance of practice team and care system Involve the family, community and populations

11. http://www.ihs.gov/CIO/RPMS Resource & Patient Management System (RPMS) Developed in the 1980s Over 60 software applications Used at over 400 sites ‘ Every little thing she does is magic’

12. PCC Patient Database PCC Patient Database Case Management Data Entry Referred Care Diabetes Management Elder Care Patient Registration Laboratory Emergency Room Public Health Nursing Pharmacy Appointment System Occupational Med CHR Radiology Immunizations Women’s Health Dental Behavioral Health PCC ( Health data repository)

13. Meaningful Use and Pop Health Quality measures for populations Populated by patients Ability to report at POC as well as export Tracking of quality improvement Ability to share interoperable data with others Immunization data sharing Lab data sharing Early sentinel awareness of public health issues Use of iCARE Suicidal Behavior Surveillance CDC Nationally Notifiable Diseases H1N1

16. 16 iCare Population Management

17. iCare is Used to…. ( in descending order ) Track performance on GPRA and other national measures Manage and track group of patients with a chronic disease Pre-visit or clinic planning to care for patients with appointments on a particular day Manage and track patients assigned to specific provider Track patients who need or have received a specific service Track provision of age and gender-specific preventive care services Share panel among care team Target needs within a geographic area or community Facilities who are part of the IHS Learning Collaborative more frequently reported using iCare for all of these listed functions with the exception of targeting geographic areas

18. H1N1 Decision made on a Friday to code query and export file Codes reviewed/ tested/ updated on Q man queries at large live database Query logic developed over 4 hours- based on previous quality work Export logic based on previous work done on bidirectional state based immunization data sharing Coding done in 8 hours Testing in 2 days on 3 mirror live data bases First exports received within 5 working days of initial decision Over 400 sites with passive nightly exports to Indian Health Service epi center Logic shared with private vendors

19. Lessons Learned-or why could we do this? Relied on ICD codes, not text based POV Our “EA” had been, by luck, designed to facilitate boolian logic queries (we knew had to have ‘function’ between the domains) Applications developed in the last 10 years had relied on electronic queries of different data domains Export files had been previously developed Lessons learned had influenced data model decisions as well as understanding of most efficient ways to write M queries in our system Logic/ data model that supported population health EHR architecture MUST support pop health from the beginning

20. what matters?  Foresight  Trust  Commitment  Adequate Resources  Appropriate architecture for the Electronic Health Record to support population health  Health Equity- keeping an eye on the ball

21. Indian Health Service http://www.ihs.gov