1. more information © 2015 Denver Public Health Tobacco Metrics: the Power of Electronic Health Records Theresa Mickiewicz, MSPH Public Health in the Rockies September 16, 2015

2. more information © 2015 Denver Public Health Dr. Bill Burman, MD: Director of Denver Public Health Dr. Arthur Davidson, MD: Director of Public Health Informatics, Epidemiology and Preparedness Emily McCormick, MPH : Epidemiologist Tracey Richers-Maruyama: Tobacco Program Manager Denver Public Health Colleagues

3. more information © 2015 Denver Public Health “The truth is rarely pure and never simple.” Oscar Wilde The Truth

4. more information © 2015 Denver Public Health Objective Describe how electronic health record (EHR) data can be a powerful complement to traditional surveillance sources in program evaluation.

5. more information © 2015 Denver Public Health Background Tobacco control and prevention are critical public health functions Many interventions are applied at the local level Need timely, specific data for evaluation More data today than yesterday and data are more readily available Meaningful use through the HITECH Act (2009)

6. more information © 2015 Denver Public Health Methods Compare three datasets: Trends Timeliness Representativeness Granularity Reliability

7. more information © 2015 Denver Public Health Behavioral Risk Factor Surveillance System (BRFSS) Used to monitor health behaviors among adults A primary data source A survey administered via telephone Anonymous Self-report Weighted to represent Colorado, some regional areas A way to compare estimates and trends in health behaviors across states and the US

8. more information © 2015 Denver Public Health Colorado Health Observation Regional Data Service (CHORDS) A collaborative regional pilot project that uses EHR data to monitor public health trends A secondary data source Clinical data from multiple partners transformed into standardized metrics De-identified but not necessarily de-duplicated Representative of residents who seek health care A way to compare health behaviors and outcomes across and within regional areas in Colorado

9. more information © 2015 Denver Public Health Cigarette Consumption Cigarette taxes paid (at the wholesale level) Colorado-level data Very sensitive to events Short lag time for availability of monthly estimates

10. more information © 2015 Denver Public Health Trends

11. more information © 2015 Denver Public Health Timeliness Frequency of available estimates: BRFSS: Annually or every other year if sample sizes are too small for annual CHORDS: Monthly with the potential for more Consumption: Monthly, semi-annual, annual Lag-time for estimates BRFSS: 6 months after the end of the year (June) CHORDS: Monthly with potential for near real-time Consumption: about 2 months

12. more information © 2015 Denver Public Health Representativeness BRFSS is designed to represent the population of interest but is limited in cases of small geographies/sub-strata analyses CHORDS represents those who seek health care but may over-count individuals CHORDS includes all ages whereas BRFSS includes adults. In most cases, CHORDS metrics are derived from clinical data and BRFSS are self-report Consumption data represents those who smoke cigarettes but excludes other types of tobacco and does not capture cigarettes procured over the internet, on the black market or in another state

13. more information © 2015 Denver Public Health Representativeness Demographic Distributions Among Denver Adults, 2014: Comparing CHORDS and BRFSS to the US Census US CensusBRFSSCHORDS* N%n%n% Overall Adults (18+)514,308100%1,291100%232,214100% Gender Females257,78850%69748%147,91264% Males256,52050%59452%84,30236% *includes unique individuals with a 2014 primary care visit where tobacco screening occurred

14. more information © 2015 Denver Public Health Granularity At a geographic level: BRFSS: – State/US – Health Statistic Region – Large County level CHORDS: – Regional or County level – Council District – Neighborhood or census tract Consumption: – State level

15. more information © 2015 Denver Public Health Granularity

16. more information © 2015 Denver Public Health Granularity Prevalence of Smoking by Demographic Strata Among Denver Adults: 2014 BRFSSCHORDS* n%95% CIn% Overall Adults (18 +)114217.2%14.5%-19.9%232,21412.7%12.5%-12.8% Race/Ethnicity Black10829.3%13.8%-33.3%17,31123.0%22.4%-23.6% Hispanic25816.2%13.8%-24.8%46,94214.4%14.1%-14.8% Other48**25,48311.1%10.7%-11.4% White69922.0%11.0%-17.5%142,47811.1%11.0%-11.3%

17. more information © 2015 Denver Public Health Reliability

18. more information © 2015 Denver Public Health Conclusions For evaluation of local level programming, EHR data: – Are more sensitive to programmatic activities – Are more timely – Allow for sub-strata analyses – Are less representative of the entire population In the era of the HITECH Act and meaningful use, the time is right to pursue public health/clinical partnerships

19. more information © 2015 Denver Public Health Discussion How could EHR data advance and enhance your programmatic activities?

20. more information © 2015 Denver Public Health CHORDS Appendix Registry Topic area Example health questions that CHORDS can trackExample of relevant data fields Obesity What percent of adults are at a healthy weight? What percent of children are at a healthy weight? Height Weight Body Mass Index (BMI) Tobacco Use and Exposure What percent of adults are screened for tobacco use? What percent of adults use tobacco? What percent of children are screened for exposure to secondhand tobacco smoke? What percent of children are exposed to secondhand tobacco smoke? Tobacco use Secondhand tobacco smoke exposure Cardiovascular Disease What percent of adults are screened for high blood pressure (known as hypertension)? What percent of adults have been diagnosed with high blood pressure (known as hypertension)? What percent of adults are screened for high cholesterol? What percent of adults have been diagnosed with high cholesterol? Blood pressure levels Diagnosis of hypertension Cholesterol test results Diagnosis of high cholesterol Future: Mental Health What percent of adults have been diagnosed with depression? What percent of adolescents have been diagnosed with depression? Diagnosis of depression