2019 09 - EHRs - PT Management

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 © 2019
For as long as I have wanted to
be a clinician, I have also loved
science and computers.
Info…what?
Biomedical informaticians collect important
health information. We organize, analyze, and
convert data into knowledge, and then we use
technology to apply that knowledge to improve
health and health care.
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…
📷 lara604 | cc-by
The EHR steals 60 minutes a day from me!
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
Intern Med. 2014 Nov;174(11):1860-3. PMID: 25200944.
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.
4x
improvement of overdue clinical tasks!
(68% vs 18%)
Saving lives or
stealing sunshine?
The Future
Great Scott!
📷 jdhancock | cc-by
Complete, longitudinal information
that follows the person
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
" 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 meerkat
📷 CaptionTime
meerkat meerkat mere cat meerkat
📷 CaptionTime
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
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
🌐 Source: APTA
Provisions for certification that
information be “accessed, exchanged and
used without special effort” through
technologies such as open application
programming interfaces (API).
Electronic Health Record
vendor adoption of
Application Programming
Interfaces
In Fall 2018, almost 87% of hospitals and
69% of MIPS eligible clinicians are served by
health IT developers with product(s) certified
to the FHIR API standard.
https://www.healthit.gov/buzz-blog/interoperability/heat-wave-the-u-s-is-poised-to-catch-fhir-in-2019
Apple Health Records
Uses Argonaut FHIR API
https://www.apple.com/healthcare/health-records/
https://support.apple.com/en-us/HT208647
Apple Health Records
Uses Argonaut FHIR API
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
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
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.
🌐 Source: IHIE
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
https://apps.smarthealthit.org
https://www.act.md
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
75856-5
#Falls in past 1Y
66247-8
Sit to stand [30 sec]
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]
…
http://www.ptoutcomes.com
Same data for…
Informing clinical care
Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
Data Analytics
📰 Source: Harvard Business Review
What we (mostly) do today
#
Interpret
Focus
Analyze data
Area
Coalesce data
Go Decision
🌐 Adapted From: Learning Health Care Project
What we (mostly) do today
#
Interpret Publish journal article
Hold inservice
Focus
Analyze data
Area
Coalesce data
Go Decision
What we need: Continuous Learning
#
Interpret Deliver Tailored Messages
Focus
Analyze data
Area
Coalesce data Take Action!
Go Decision
What we need: Continuous Learning
#
Interpret Deliver Tailored Messages
Persistent and sharable Right time, place, audience, format
knowledge
Focus
Analyze data
Area
Data Science Methods
Coalesce data Take Action!

Data policies, standards Capture changed practice
Go Decision
🌐 Adapted From: Learning Health Care Project Forming Communities of Interest
📷 duncan | cc-by-nc
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
Our central insight is that rather than explicitly
harmonizing EHR data, mapping it into a highly curated set
of structured predictors variables and then feeding those
variables into a statistical model, we can instead learn to
simultaneously harmonize inputs and predict medical events
through direct feature learning.
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).
What this can look like in rehabilitation
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
Some words of caution
📰 Source: STAT
Medical information that is revealed to health
care providers is protected by privacy laws such
as the Health Information Portability and
Accountability Act (HIPAA). In contrast, emergent
medical data receives virtually no legal
protection. By mining it, companies sidestep
privacy and anti-discrimination laws to obtain
information most people would rather not disclose.
📰 Source: STAT
HIPAA
HIPAA Right of Access
Accepts requests by email or fax: Providers may not create a barrier to access by
requiring patients to submit requests in person or by mail.
Sent in format requested to the patient’s designated recipient: The provider

sends the records in the format the patient requests, which is in digital form by email
for text, CD for images, and sends it to the third party designated by the patient.
Sent within 30 days*: The provider responds to the request within 30 days of
receipt.
No unreasonable fees: Providers may only charge reasonable, cost-based (i.e.,

minimal) fees to cover labor costs of copying and supplies.
https://www.ciitizen.com/scorecard/
continuous glucose monitor
+
insulin pump
+
computerized control system
📰 Source: NEO.LIFE
Clinical Decision Making
Right info. Right time. Right format.
Evidence-based Practice
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.
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!
Limit to reviews (n=2827)
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
https://www.youtube.com/user/thehealthcaretriage/
Your Turn
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?
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.
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.
Most common
complaint?
anecdotal
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.
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.
…tailor the reminder to existing clinic
setups and workflows.
My Summary:
Reminders can help, but healthcare is
complex (because it involves people)!
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 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.
…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.
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.
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.
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.
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.

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
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.
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
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
📷 scragz | cc-by
📷 scragz | cc-by
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
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SHRS-P 664 Administration and Management of Physical Therapy Services

Using Health Information Technology

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

Director, LOINC and Health Data Standards

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

photo via Verino77

The EHR steals 60 minutes a day from me!

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

Social and community determinants

Similar name. Different Meaning.

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

If {# Falls in last year} > 0

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]

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

Coalesce data Take Action!

Coalesce data Take Action!

Sent in format requested to the patient’s designated recipient: The provider

No unreasonable fees: Providers may only charge reasonable, cost-based (i.e.,

Everyone wants it.

Everyone wants it.

photo via liber

If {Hgb < 8 gm/dL}

Be mindful of the complexity.

This is similar to assuming that a

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