Sripriya Rajamani

Increasing rates of hospitalization due to septicemia in the US elderly population, 1986-1997.

Rates of hospitalization due to septicemia (International Classification of Diseases, Ninth Revision, Clinical Modification, code 038) in the US elderly population for 1986-1997 were examined, using Medicare administrative data. Age group-, sex-, and race-adjusted rates more than doubled from 1986 through 1997, from 3.42 to 7.42 per 1000 beneficiaries. The 1997 rates of septicemia increased with age, from 4.47 per 1000 beneficiaries among persons 65-74 years old to 18.1 per 1000 beneficiaries among persons > or =85 years old. The rates of septicemia were slightly greater among men (7.46 per 1000 beneficiaries) than among women (7.39 per 1000 beneficiaries) and were higher among blacks (13.61 per 1000 beneficiaries) than among whites (6.89 per 1000 beneficiaries). The most likely sites of the origin of the septicemia were the urinary tract (40.1%) and lungs (15.3%). Escherichia coli and Staphylococcus species were the most frequently reported organisms. Diabetes was listed as a comorbidity in 24.5% of the hospitalizations. We estimate that the cost to Medicare for septicemia hospitalizations in 1997 was >

Assessing the adequacy of the HL7/LOINC Document Ontology Role axis.

1.8 billion.

Technological and Organizational Context around Immunization Reporting and Interoperability in Minnesota

The healthcare landscape is changing, driven by innovative care models and the emergence of new roles that are inter-professional in nature. Currently, the HL7/LOINC Document Ontology (DO) aids the use and exchange of clinical documents using a multi-axis structure of document attributes for Kind of Document, Setting, Role, Subject Matter Domain, and Type of Service. In this study, the adequacy of the Role axis for representing the type of author documenting care was assessed. Experts used a master list of 220 values created from seven resources and established mapping guidelines. Baseline certification, licensure, and didactic training were identified as key parameters that define roles and hence often need to be pre-coordinated. DO was inadequate in representing 82% of roles, and this gap was primarily due to lack of granularity in DO. Next steps include refinement of the proposed schema for the Role axis and dissemination within the larger standards community.

Characterizing the Access of Clinical Decision Support Offered by Immunization Information System in Minnesota

Background: Immunization information systems (IIS) operate in an evolving health care landscape with technology changes driven by initiatives such as the Centers for Medicare and Medicaid Services EHR incentive program, promoting adoption and use of electronic health record (EHR) systems, including standards-based public health reporting. There is flux in organizational affiliations to support models such as accountable care organizations (ACO). These impact institutional structure of how reporting of immunizations occurs and the methods adopted. Objectives: To evaluate the technical and organizational characteristics of healthcare provider reporting of immunizations to public health in Minnesota and to assess the adoption of standardized codes, formats and transport. Methods: Data on organizations and reporting status was obtained from Minnesota IIS (Minnesota Immunization Information Connection: MIIC) by collating information from existing lists, specialized queries and review of annual reports. EHR adoption data of clinics was obtained in collaboration with informatics office supporting the Minnesota e-Health Initiative. These data from various sources were merged, checked for quality to create a current state assessment of immunization reporting and results validated with subject matter experts. Results: Standards-based reporting of immunizations to MIIC increased to 708 sites over the last 3 years. A growth in automated real-time reporting occurred in 2013 with 143 new sites adopting the method. Though the uptake of message standards (HL7) has increased, the adoption of current version of HL7 and web services transport remains low. The EHR landscape is dominated by a single vendor (used by 40% of clinics) in the state. There is trend towards centralized reporting of immunizations with an organizational unit reporting for many sites ranging from 4 to 140 sites. Conclusion: High EHR adoption in Minnesota, predominance of a vendor in the market, and centralized reporting models present opportunities for better interoperability and also adaptation of strategies to fit this landscape. It is essential for IIS managers to have a good understanding of their constituent landscape for technical assistance and program planning purposes.

Partnership to promote interprofessional education and practice for population and public health informatics: A case study

Background: Healthy People 2020 aims to improve population health by increasing immunization rates to decrease vaccine-preventable infectious diseases. Amongst the many strategies, role of immunization information systems (IIS) are recognized by studies and taskforce reports. IIS are unique in their offering of clinical decision support for immunizations (CDSi) which are utilized by healthcare providers. Federal initiatives such as Meaningful Use (MU) and Affordable Care Act (ACA) aim to improve immunization rates through use of technology and expanding access to immunization services respectively. MU, the Electronic Health Record (EHR) incentive program includes use of IIS CDSi functionality as part of Stage 3. It is essential to understand access and use patterns of IIS CDSi, so as to utilize it better to improve immunization services. Objectives: To understand the utilization of clinical decision support for immunizations (CDSi) offered by immunization information system in Minnesota and to analyze the variability of its use across providers and EHR implementations. Methods: IIS in Minnesota (Minnesota Immunization Information Connection: MIIC) offers CDSi that is accessed through EHRs and branded as Alternate Access (AA). Data from MIIC and technical documents were reviewed to create details on organizations which implemented AA functionality. Data on EHR adoption in clinics and local health departments was obtained from Minnesota eHealth assessment reports. Data on access were tracked from January 2015 through mid-October 2015 through weekly specialized reports to track the queries by organization, volume and day of the week. Data were analyzed, findings were synthesized and reviewed with subject matter experts. Results: Currently 25 healthcare systems/organizations which represent 599 individual provider sites have implemented the AA functionality. Analysis of their EHR platform pointed to two EHRs (Epic and PH-Doc) as dominant products in Minnesota for private and public providers respectively. Use of this function was even across study time period. The query volume correlated to size of the organization, with the exception of an outlier organization with huge query count. Query was able to successfully locate a single matching record for 59% of searches, could not find a record for 5% and 31% resulted in blank/error and the match rates varied across health systems. Conclusion: High EHR adoption offers a great opportunity to promote use of IIS CDSi at point of care. Analysis did not track use at individual clinic level and how the queries were being generated. Additional research is needed to understand the provider level use of this CDSi and other organizational and technical factors which influence access to IIS. This is essential for IIS as they execute projects to improve population-level immunization rates, plan provider outreach and prioritize their system enhancements to meet federal requirements.

Evaluation of Data Exchange Process for Interoperability and Impact on Electronic Laboratory Reporting Quality to a State Public Health Agency

Abstract Team-based healthcare delivery models, which emphasize care coordination, patient engagement, and utilization of health information technology, are emerging. To achieve these models, expertise in interprofessional education, collaborative practice across professions, and informatics is essential. This case study from informatics programs in the Academic Health Center (AHC) at the University of Minnesota and the Office of Health Information Technology (OHIT) at the Minnesota Department of Health presents an academic–practice partnership, which focuses on both interprofessionalism and informatics. Outcomes include the Minnesota Framework for Interprofessional Biomedical Health Informatics, comprising collaborative curriculum development, teaching and research, practicums to promote competencies, service to advance biomedical health informatics, and collaborative environments to facilitate a learning health system. Details on these Framework categories are presented. Partnership success is due to interprofessional connections created with emphasis on informatics and to committed leadership across partners. A limitation of this collaboration is the need for formal agreements outlining resources and roles, which are vital for sustainability. This partnership addresses a recommendation on the future of interprofessionalism: that both education and practice sectors be attuned to each other’s expectations and evolving trends. Success strategies and lessons learned from collaborations, such as that of the AHC-OHIT that promote both interprofessionalism and informatics, need to be shared.

Representation of occupational information across resources and validation of the occupational data for health model

Background Past and present national initiatives advocate for electronic exchange of health data and emphasize interoperability. The critical role of public health in the context of disease surveillance was recognized with recommendations for electronic laboratory reporting (ELR). Many public health agencies have seen a trend towards centralization of information technology services which adds another layer of complexity to interoperability efforts. Objectives The study objective was to understand the process of data exchange and its impact on the quality of data being transmitted in the context of electronic laboratory reporting to public health. This was conducted in context of Minnesota Electronic Disease Surveillance System (MEDSS), the public health information system for supporting infectious disease surveillance in Minnesota. Data Quality (DQ) dimensions by Strong et al., was chosen as the guiding framework for evaluation. Methods The process of assessing data exchange for electronic lab reporting and its impact was a mixed methods approach with qualitative data obtained through expert discussions and quantitative data obtained from queries of the MEDSS system. Interviews were conducted in an open-ended format from November 2017 through February 2018. Based on these discussions, two high level categories of data exchange process which could impact data quality were identified: onboarding for electronic lab reporting and internal data exchange routing. This in turn comprised of ten critical steps and its impact on quality of data was identified through expert input. This was followed by analysis of data in MEDSS by various criteria identified by the informatics team. Results All DQ metrics (Intrinsic DQ, Contextual DQ, Representational DQ, and Accessibility DQ) were impacted in the data exchange process with varying influence on DQ dimensions. Some errors such as improper mapping in electronic health records (EHRs) and laboratory information systems had a cascading effect and can pass through technical filters and go undetected till use of data by epidemiologists. Some DQ dimensions such as accuracy, relevancy, value-added data and interpretability are more dependent on users at either end of the data exchange spectrum, the relevant clinical groups and the public health program professionals. The study revealed that data quality is dynamic and on-going oversight is a combined effort by MEDSS Informatics team and review by technical and public health program professionals. Conclusion With increasing electronic reporting to public health, there is a need to understand the current processes for electronic exchange and their impact on quality of data. This study focused on electronic laboratory reporting to public health and analyzed both onboarding and internal data exchange processes. Insights gathered from this research can be applied to other public health reporting currently (e.g. immunizations) and will be valuable in planning for electronic case reporting in near future.

Developing Workforce Capacity in Public Health Informatics: Core Competencies and Curriculum Design

Reports by the National Academy of Medicine and leading public health organizations advocate including occupational information as part of an individuals social context. Given recent National Academy of Medicine recommendations on occupation-related data in the electronic health record, there is a critical need for improved representation. The National Institute for Occupational Safety and Health has developed an Occupational Data for Health (ODH) model, currently in draft format. This study aimed to validate the ODH model by mapping occupation-related elements from resources representing recommendations, standards, public health reports and surveys, and research measures, along with preliminary evaluation of associated value sets. All 247 occupation-related items across 20 resources mapped to the ODH model. Recommended value sets had high variability across the evaluated resources. This study demonstrates the ODH models value, the multifaceted nature of occupation information, and the critical need for occupation value sets to support clinical care, population health, and research.

Assessing the representation of occupation information in free-text clinical documents across multiple sources

We describe a master’s level public health informatics (PHI) curriculum to support workforce development. Public health decision-making requires intensive information management to organize responses to health threats and develop effective health education and promotion. PHI competencies prepare the public health workforce to design and implement these information systems. The objective for a Master’s and Certificate in PHI is to prepare public health informaticians with the competencies to work collaboratively with colleagues in public health and other health professions to design and develop information systems that support population health improvement. The PHI competencies are drawn from computer, information, and organizational sciences. A curriculum is proposed to deliver the competencies and result of a pilot PHI program is presented. Since the public health workforce needs to use information technology effectively to improve population health, it is essential for public health academic institutions to develop and implement PHI workforce training programs.

Health Reform in Minnesota: An Analysis of Complementary Initiatives Implementing Electronic Health Record Technology and Care Coordination

There has been increasing recognition of the key role of social determinants like occupation on health. Given the relatively poor understanding of occupation information in electronic health records (EHRs), we sought to characterize occupation information within free-text clinical document sources. From six distinct clinical sources, 868 total occupation-related sentences were identified for the study corpus. Building off approaches from previous studies, refined annotation guidelines were created using the National Institute for Occupational Safety and Health Occupational Data for Health data model with elements added to increase granularity. Our corpus generated 2,005 total annotations representing 39 of 41 entity types from the enhanced data model. Highest frequency entities were: Occupation Description (17.7%); Employment Status - Not Specified (12.5%); Employer Name (11.0%); Subject (9.8%); Industry Description (6.2%). Our findings support the value of standardizing entry of EHR occupation information to improve data quality for improved patient care and secondary uses of this information.