Continuity of Care Record as a Tool to Use Data Captured by 3rd Party Sources: Where we are now and

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Continuity of Care Record as a Tool to Use Data
Captured by 3rd Party Sources Where we are now
and where we would like to be

• Stasia Kahn, MD
• Fox Prairie Medical Group
• Northern Illinois Physicians For Connectivity
• Vikram Sheshadri, PhD
• Emedapps, Inc.

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Motivation for Implementing CCR

• The CCR can be tailored meet the needs of the
  intended consultant
• Patients frequently dont bring their complete up
  to date medication lists with them when they
  travel to and from healthcare providers
• Patients often forget what lab tests they have
  had done and by whom
• Primary care physicians are notoriously bad at
  communicating with their consultants

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Why Wait?

• Vendors are starting to implement CCR support at
  different rates
• A practice can implement the CCR schema without
  waiting for their EMR vendor by working with an
  IT consultant who is familiar with XML
• Physicians working in an EHR can send CCRs to
  physicians who do not have an EHR to improve
  patient safety and avoid duplication of tests
  that drive healthcare costs higher
• CCRs can be sent in areas that do not have
  regional health exchange networks by using a
  community portal or by using an encryption device

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Continuity of Care Record Pilot in Illinois

• June 8 2005 ASTM CCR successfully balloted
• September 1, 2005 first electronic transfer of
  CCR from one electronic health record to two
  other physicians practicing with electronic
  health records in Illinois
• September 8, 2005 first CCR sent for purpose of
  sharing health information to a cardiologist
• Total of 14 CCRs in Illinois and 1 in Florida
• Receiving physicians are representatives of
  small, medium and large academic and private
  groups.

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CCR Pilot 2005

• September 2005 first CCR sent to cardiologist in
  single specialty practice(using EHR)
• October sent CCR to Oncologist in single
  speciality practice
• December sent CCR to Neuro oncologist and ENT
  physician seeing patient in the same week at
  Evanston Northwestern Healthcare

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CCR Pilot 2006

• January sent CCR to Internist in Sarasota Florida
  for patient transfer over winter months
• January sent CCR to Urologist in single specialty
  practice (using EHR)
• February sent CCR to Hematologist Oncologist and
  Urologist (using EHR) seeing patient at different
  single specialty practices within the month
• April sent CCR to Hematologist Oncologist in
  single specialty practice
• May sent CCR to Neurologist in multi specialty
  practice

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CCR Pilot 2007

• Sent CCR to Surgeon at Northwestern Healthcare
• Sent CCR to Gastroenterologist at multi
  specialty practice on the verge of implementing
  an EHR
• Sent CCR to the afore mentioned
  Gastroenterologist at multi specialty group
  practice
• Sent CCR to Cardiologist at single specialty
  group practice working within an EHR for
  consultation
• Sent CCR to the afore mentioned Cardiologist at
  single specialty group for medical records update
• An additional Internist in the western suburbs of
  Chicago who is unaffiliated with Fox Prairie
  Medical Group has added CCR functionality to her
  EMR and will be using the CCR to improve patient
  care

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What makes CCR ideal for data transfer

• The CCR uses XML based on World Wide Web
  Consortium rules which have already been
  successfully used in other industries to share
  secure data across disparate institutions
  (Banking Industry)
• The CCR can be expressed in mixed media
  including of USB devices, cell phones, CDs, and
  yes even paper.
• The CCR can function as an exchange media between
  personal health records and EHRs thereby linking
  patients and their physicians electronically

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CCR Pilot Details

• Built seamless tool to extract information from
  patient clinical data based on selections from
  the physician and create a CCR compliant XML
  document
• Using a portal to exchange the CCR with other
  physicians
• Portal allows physicians to securely view CCR,
  download to disk, print or where appropriate
  import directly into EHR

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CCR Exchange
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Summary

• Feedback
• 15 CCRs uploaded to the portal
• 1 failure -CCR was not accessed
• 1 imported directly into EHR
• 4 Viewed online by the provider
• 9 had someone else print the CCR

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Lessons Learned

• If at all possible call the receiving physician
  ahead of time (a week or more ideally)
• Confirm the email address of either the
  administrator or physician who will be accessing
  the portal
• Do not rely on the CCR for pre-surgical clearance
  unless the receiving provider has accepted
  responsibility for downloading or printing the
  CCR.

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Can we extend the use of the CCR?

• Providers sharing data with patients
• Patients sharing data with providers
• Families sharing data with providers and each
  other
• Purchasers of healthcare sharing data with
  patients and providers
• Pharmacies sharing data with providers and
  patients

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How does the Illinois CCR pilot fit into a
discussion on information capture?

• CCR is a data capture mechanism which can also be
  used for information exchange
• CCR is an easy way to aggregate information from
  a patients or providers electronic health
  record
• Once a CCR generator has been imbedded in an EMR
  or PHR system, and appropriate communication
  protocols defined they can share data
• In order for recipients of CCRs to be able to
  parse data elements, industry, consumers, and
  providers need to work together to solve a series
  of obstacles which we will outline in the
  remainder of this presentation.

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Obstacles to 3rd party data exchange

• Identifying the creator and sources of data
• Tracking the creator and sources of data
• Restricting access to certain portions of a CCR
• Restricting access to certain providers
• Limiting the IT burden on providers who agree
  to accept asynchronous CCRs from outside sources
  including patients and payers
• Defining informed consent

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Obstacles - Identifying the creator and sources
of data

• Important to identify and differentiate whether a
  diagnosis or medication entry originated from a
  healthcare provider or patient
• Fraud and errors in medications and diagnosis
  could be perpetuated
• Patients have not been educated to code data in a
  structured format. Personal Health Record past
  medical history and medication entries allows for
  unstructured data
• Entries from patients should not be used for
  billing purposes or take the place of a dialogue
  between a healthcare provider and patient
• A patient could be labeled or treated
  inappropriately because of their own
  misunderstanding of the nuances of coding
  structured data
• Providers vary in their familiarity with
  structured data pertaining to other medical
  specialties

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Obstacles - Tracking the Creator and Sources of
Data

• Need to differentiate between the creator and
  source of external data and be able to track both
• Currently EMR systems will tag all data entered
  via the EMR by user ID
• EMR vendors would need to be required to identify
  the creator and the source of all structured
  data as coming in from an external source
• EMR vendors would need to be required to tag the
  originator of all structured data fields
• EMR vendors would need to be required to have
  tracking mechanisms in place to allow data
  sources to flow across disparate electronic
  health records systems

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Obstacles - Restricting Access to Portions of an
EMR

• Is it feasible for a provider to designate that
  portions of a document are restricted.
• Yes-structured data such as medications or
  diagnosis could be tagged as restricted access
  and wouldnt be shared by default when generating
  a CCR
• It would be technically difficult to suppress
  restricted information in unstructured data that
  contains both restricted and unrestricted
  information
• An office note that intermingles medical and
  psychiatric problems, medical and drug, alcohol,
  or HIV treatment
• For further information on restricting access see
  Mandl et al.

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Obstacles - Restricting Assess to different
providers

• Should a patient be allowed to give access to
  certain providers to specific portions of their
  medical record and exclude others?
• Who would be responsible for keeping a patients
  preferences up to date?
• What would be the consequences of releasing data
  to a unauthorized providers?
• For further information on role based
  authentication and access privileges see Simons
  et al.

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Obstacles - There are no requirements in place
for EHRs to upload patient managed Personal
Health Records

• If a provider is able to import a CCR from
  another provider they should be able to import a
  CCR from a patient
• A practice will have come up with an office
  policy that outlines which if any portable
  memory devices they will allow to connect with
  their server
• If a patient utilizes a Web based PMR a practice
  will have to come up with office policies on the
  number of CCR(PHR) uploads will allowed per
  patient and over what time frame and whether the
  uploads must occur synchronous to an office
  visit. A practice will also have to designate an
  employee that is responsibxle for tracking
  patient requests for uploads.
• For further information see People Chart call for
  action

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Obstacles Defining informed consent

• According to Kluge standards of disclosure and
  standards of comprehension may vary
• Patients have the expectation that information
  about them recorded in a healthcare encounter
  will be used soley for therapeutic purposes.
• If we accept this notion then we will need to
  define therapeutic purposes which by itself is a
  challenge
• For example does a cardiologist need to know that
  I treated my patient for a vaginal infection 2
  months ago..
• Additional issues arise when we take into account
  that the person we are sending this data to may
  not only consume the data but may resend the data
  as well.

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Questions raised from the Illinois CCR pilot

• Is it necessary for a provider to share all
  healthcare information with a consultant provider
  that is available in a patients electronic
  medical record?
• NO
• Is it feasible to expect providers who are
  sharing electronic protected health information
  (EPHI) to choose only those data elements about a
  patient that are therapeutic
• Maybe
• Should a patient be able to view the electronic
  healthcare data that a provider shares with a
  consulting provider?
• YES but this would require a change in workflow
• If my patient objects to the content of their
  EPHI how would a provider handle their
  objections?
• Delicately

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Next Steps

• Import CCR data as structured data
• This is dependent on EMR vendors addressing the
  data integrity issues brought up earlier
• Engage consumers in using Personal Health Records
  and allow for the exchange of PHR data into EHRs

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Engage Consumers in using Personal Health Records
and allow for the exchange of PHR data into EHRs

• A volunteer panel of 50 plus experts has been
  assembled by Northern Illinois Physicians For
  Connectivity and the Chicago Patient Safety Forum
  for the purpose of engaging Illinois consumers in
  using Personal Health Records and solving
  connectivity issues to allow the transfer of data
  between Personal Health Records and Electronic
  Health Records. The deliverable of the expert
  panel will be the White Paper for an Illinois
  Personal health Record.

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White Paper for an Illinois Personal Health Record

• Chapters/Subchapters
• Providers of Healthcare including Pharmacists,
  Integrated Delivery System Providers, Academic
  Providers, Private Hospitals and Employed
  Providers, Independent Providers, Long Term Care
  Facilities, State and Local Health Departments,
  Federally Qualified and Free Health Clinics,
  Nurses
• Purchasers of Healthcare including State Public
  Aid, Employers and Commercial Insurance
• Consumers of Healthcare
• Challenges Specific to Rural Healthcare
• Technical Issues including EMR vendors, PHR
  vendors, and PHR to EHR Connectivity
• Privacy and Security Issues
• Business Model

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Volunteer Authors/Editors

• Vendor Community Axolotl, Sun Microsystems,
  Misys, Nextgen,McKesson, RelayHealth,Records for
  Living,CCR Exchange,Good Health Network, Baxter
  International
• Information Technology and Healthcare
  Consultants E-medapps,Tech Alliance, Healthcare
  Research Associates,G. Murphy and Associates,
  Blackwell Consulting Services, Firmware
  Solutions, Michael Pine and Associates, Benefit
  Performance Associates, CQuest America, LAI
  Technology
• Northwestern Memorial Hospital and University,
  University of Chicago and University of Illinois
  Faculty and Students
• University HealthSystem Consortium
• Integrated Delivery Systems Adventist Health
  Network, Advocate, Sisters of Mercy
• Healthcare Providers Fox Prairie Medical Group,
  Delnor Community Hospital, Central DuPage
  Hospital, Rush Copley Medical Center, Condell
  Health Network, Illinois Primary Care Healthcare
  Association
• Commercial InsuranceHarmony Health Plan,
  MEDecision
• Walgreens Corporation
• Midwest Business Group on Health
• Illinois Department of Public Health
• Office of the Lt. Gov Patrick Quinn
• Illinois Chamber of Commerce Healthcare Council
• HIMSS

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White Paper for an Illinois Personal Health
Record website can be viewed at
http//www.emr-pmr.comVolunteers are still
welcome including editors and publishersIntereste
d persons or organizations please contact
Skahn_at_niphysiciansforconnectivity.org

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BibliographyMandle, KD et al. Public Standards
and Patients Control how to keep electronic
medical records accessible but private, British
Medical Journal 2001322283-287.Simons, WW et
al. The Ping Personally Controlled Electronic
Medical Records System Technical Architecture,
JAMIA 29 20051247-54PeopleChart. Call for
Action Electronic Data Exchange Capabilities Must
be Shared with PHRs AHIC 09/17/06Kluge E-HW.
Informed Consent to the Secondary Use of EHRs
Informatics rights and their limitation, MEDINFO
2004635-638.

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Questions

• For further information
• Stasia Kahn skahn_at_niphysiciansforconnectivity.org
  
• Vikram Sheshadri sheshadv_at_emedapps.com
• [phone]
• Booth 407