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Howard Hays, MD, MSPHRPMS Program Manager, IHS
Howard Hays, MD, MSPHRPMS Program Manager, IHS
World VistA CommunityJune 16, 2007
Indian Health ServiceIndian Health Service
• Provides comprehensive care to over 1.6 million American Indians / Alaska Natives
• Nearly 600 health care facilitiesFederal
Tribal
Hospitals 36 13
Health Centers 61 158
Health Stations 49 76
Residential treatment centers 5 28
Alaska village clinics 170
Urban programs 34
• Provides comprehensive care to over 1.6 million American Indians / Alaska Natives
• Nearly 600 health care facilitiesFederal
Tribal
Hospitals 36 13
Health Centers 61 158
Health Stations 49 76
Residential treatment centers 5 28
Alaska village clinics 170
Urban programs 34
Indian Health ServiceIndian Health Service• Over 50% of programs are operated by tribes
through tribally run compacted or contracted facilities
• 34 urban programs are contracted to provide care to AI/AN populations in metropolitan areas
• Remaining care is provided through federally operated ‘direct’ programs (majority of the user population still receives care in direct programs)
• Over 50% of programs are operated by tribes through tribally run compacted or contracted facilities
• 34 urban programs are contracted to provide care to AI/AN populations in metropolitan areas
• Remaining care is provided through federally operated ‘direct’ programs (majority of the user population still receives care in direct programs)
Data NeedsData Needs• Clinical care
– Provision of care (diagnoses, meds, results, etc.)– Assessment of quality of care
• Public Health Surveillance– Fluoridation, Immunization, Suicide, DV/IPV, etc.
• Billing / Collections– Diagnosis and service codes
• Research– Collaborations with CDC, AHRQ, academia
• Performance Assessment– GPRA and other national measures
• Legislative– Congressional reports, budget justification, etc.
• Clinical care– Provision of care (diagnoses, meds, results, etc.)– Assessment of quality of care
• Public Health Surveillance– Fluoridation, Immunization, Suicide, DV/IPV, etc.
• Billing / Collections– Diagnosis and service codes
• Research– Collaborations with CDC, AHRQ, academia
• Performance Assessment– GPRA and other national measures
• Legislative– Congressional reports, budget justification, etc.
Data Issues in IHSData Issues in IHS
• Funding and reporting are centralized, but administration and governance are decentralized
• Over half of Indian health programs are administered autonomously by tribes
• Submission of health data from tribes is voluntary
• Therefore, we (IHS) must provide tools for quality care and data collection that are attractive and meet the needs of all constituents, Tribal and Federal.
• Funding and reporting are centralized, but administration and governance are decentralized
• Over half of Indian health programs are administered autonomously by tribes
• Submission of health data from tribes is voluntary
• Therefore, we (IHS) must provide tools for quality care and data collection that are attractive and meet the needs of all constituents, Tribal and Federal.
RPMSRPMS
• Resource and Patient Management System
• IHS Health Information Solution since 1984
---- A.K.A. ----
Really Powerful at Measuring Stuff
• Resource and Patient Management System
• IHS Health Information Solution since 1984
---- A.K.A. ----
Really Powerful at Measuring Stuff
• RPMS is an integrated Public Health information system– Composed of over 60 component applications– Patient and Population based clinical
applications– Patient and Population based administrative
applications– Financially-oriented administrative applications
www.ihs.gov/CIO/RPMS
• RPMS is an integrated Public Health information system– Composed of over 60 component applications– Patient and Population based clinical
applications– Patient and Population based administrative
applications– Financially-oriented administrative applications
www.ihs.gov/CIO/RPMS
What is RPMS?What is RPMS?
VistA and RPMSVistA and RPMS
• Common programming/database architecture (M/Cache)
• Applications shared by VHA and IHS• Many developed for use in VHA and adapted for
IHS• Others developed for use in IHS, some adopted by
VHA• RPMS focused around Visit data contained in
Patient Care Component (PCC)• IHS uses HRN instead of SSN
• Common programming/database architecture (M/Cache)
• Applications shared by VHA and IHS• Many developed for use in VHA and adapted for
IHS• Others developed for use in IHS, some adopted by
VHA• RPMS focused around Visit data contained in
Patient Care Component (PCC)• IHS uses HRN instead of SSN
IHS is not VHAIHS is not VHA
• Cradle to grave care– Pediatrics– Prenatal and obstetrical care
• Smaller facilities, more rurally located
• Decentralized administration
• Tribal autonomy
• Community and population-based mission
• Very modest IT staffing & budget
• Cradle to grave care– Pediatrics– Prenatal and obstetrical care
• Smaller facilities, more rurally located
• Decentralized administration
• Tribal autonomy
• Community and population-based mission
• Very modest IT staffing & budget
RPMS Integrates MultipleClinical Systems
RPMS Integrates MultipleClinical Systems
The EHR Challenge for IHSThe EHR Challenge for IHS
• Produce or acquire an Electronic Health Record system that:– Meets clinical and business needs of both
Tribally and Federally operated facilities– Is scalable to the needs of facilities ranging
from small rural clinics to medium-sized hospitals
– Is affordable to facilities with no resource cushion or ability to borrow
– Is sustainable into the future
• Produce or acquire an Electronic Health Record system that:– Meets clinical and business needs of both
Tribally and Federally operated facilities– Is scalable to the needs of facilities ranging
from small rural clinics to medium-sized hospitals
– Is affordable to facilities with no resource cushion or ability to borrow
– Is sustainable into the future
RPMS – Elements of an EHR for over 20 Years
RPMS – Elements of an EHR for over 20 Years
Existing elements– Registration– Scheduling– Pharmacy– Radiology– Laboratory– Immunizations– Reminders (passive)– Problem List– Health Summary– Other PCC functions– Billing– More . . .
Existing elements– Registration– Scheduling– Pharmacy– Radiology– Laboratory– Immunizations– Reminders (passive)– Problem List– Health Summary– Other PCC functions– Billing– More . . .
Lacking elements– Provider order entry– Note authoring– Point of care data entry– GUI usability– Active reminders &
notifications
Lacking elements– Provider order entry– Note authoring– Point of care data entry– GUI usability– Active reminders &
notifications
RPMS Electronic Health RecordRPMS Electronic Health Record• Graphical User Interface to RPMS
– User-friendly and intuitive access to RPMS database for clinicians and other staff
– Componentized to allow incorporation of CPRS functionality as well as new capabilities developed within IHS
– Proprietary “framework” for presentation of various GUI components
• Graphical User Interface to RPMS– User-friendly and intuitive access to RPMS
database for clinicians and other staff
– Componentized to allow incorporation of CPRS functionality as well as new capabilities developed within IHS
– Proprietary “framework” for presentation of various GUI components
The EHR Componentized Framework
The EHR Componentized Framework
The EHR Componentized Framework
The EHR Componentized Framework
The EHR Componentized Framework
The EHR Componentized Framework
• VueCentric Design Mode– Build visual
templates from available components, arranging them on tabs or panes in an orientation consistent with the user’s workflow
• VueCentric Design Mode– Build visual
templates from available components, arranging them on tabs or panes in an orientation consistent with the user’s workflow
• VueCentric Layout Manager– Allows customization
of visual user template– Orientation via tabs,
tree views, splitter panes, etc.
– Click and drag to modify layout
– Addition of color & style enhancements
– Layout according to user’s business flow
• VueCentric Layout Manager– Allows customization
of visual user template– Orientation via tabs,
tree views, splitter panes, etc.
– Click and drag to modify layout
– Addition of color & style enhancements
– Layout according to user’s business flow
RPMS EHR Commonalities with CPRS
RPMS EHR Commonalities with CPRS
• Notifications• Text Integration Utility – note author• Reminders application
– IHS-specific national reminders
• Consults application– RPMS has separate referred care application
• Order Entry, Lab, Radiology, Pharmacy– Numerous IHS customizations esp with
medication management
• Notifications• Text Integration Utility – note author• Reminders application
– IHS-specific national reminders
• Consults application– RPMS has separate referred care application
• Order Entry, Lab, Radiology, Pharmacy– Numerous IHS customizations esp with
medication management
IHS-Specific EHR ComponentsIHS-Specific EHR Components
• Medication management interface
• Immunizations
• Patient Education
• Problem List
• Diagnosis entry and coding
• Superbills and CPT coding
• Numerous others
• Medication management interface
• Immunizations
• Patient Education
• Problem List
• Diagnosis entry and coding
• Superbills and CPT coding
• Numerous others
Other RPMS CapabilitiesOther RPMS Capabilities
• Powerful Database Query Tools• State Immunization Data Exchange• Reference Lab Interface• Support for pediatric care• Support for women’s health & prenatal• Behavioral Health applications• Multiple Case Management applications• iCare Population Management GUI• Clinical Reporting System – performance
measure application (specific to IHS)
• Powerful Database Query Tools• State Immunization Data Exchange• Reference Lab Interface• Support for pediatric care• Support for women’s health & prenatal• Behavioral Health applications• Multiple Case Management applications• iCare Population Management GUI• Clinical Reporting System – performance
measure application (specific to IHS)
Immunization Data ExchangeImmunization Data Exchange
• IHS and Tribes share many patients with private sector– Shot records are often incomplete due to
patient mobility– Risk for under- and over-immunization
• Data exchange system for pediatric immunizations developed– HL-7 data files exported to and imported from
State immunization registries
• IHS and Tribes share many patients with private sector– Shot records are often incomplete due to
patient mobility– Risk for under- and over-immunization
• Data exchange system for pediatric immunizations developed– HL-7 data files exported to and imported from
State immunization registries
Reference Lab InterfaceReference Lab Interface
• Released for Laboratory v5.2 (IHS patch 1021)
• Uni- or Bi-directional interface with contracted reference laboratories– Unidirectional receives lab results into PCC– Bidirectional sends orders to reference lab
and receives results into lab package (EHR)
• Implementation is fairly labor-intensive
• Released for Laboratory v5.2 (IHS patch 1021)
• Uni- or Bi-directional interface with contracted reference laboratories– Unidirectional receives lab results into PCC– Bidirectional sends orders to reference lab
and receives results into lab package (EHR)
• Implementation is fairly labor-intensive
Well Child CareWell Child Care• CDC Growth Charts – in PCC+ and EHR GUI• Infant birthweight & feeding choices• Ages & Stages Questionnaire (ASQ)
– Age-specific screening in 5 dimensions– Print form, record score in EHR or PCC– Guidance for abnormal screens
• Well Child Knowledgebase– Thousands of age-specific reminders, education,
developmental & medical screening, etc.– Nationally deployed set with local management
• Additional screening tools (DDST milestones)
• CDC Growth Charts – in PCC+ and EHR GUI• Infant birthweight & feeding choices• Ages & Stages Questionnaire (ASQ)
– Age-specific screening in 5 dimensions– Print form, record score in EHR or PCC– Guidance for abnormal screens
• Well Child Knowledgebase– Thousands of age-specific reminders, education,
developmental & medical screening, etc.– Nationally deployed set with local management
• Additional screening tools (DDST milestones)
Prenatal Care (in development)Prenatal Care (in development)
• Data collection and entry for:– First Prenatal Visit– Interim Prenatal Visits– Postpartum Visit
• Over 600 data points• Flowchart presentation where appropriate• Data carries over to future pregnancies• Multiple GUI components planned• Flowchart infrastructure extensible to other
types of data
• Data collection and entry for:– First Prenatal Visit– Interim Prenatal Visits– Postpartum Visit
• Over 600 data points• Flowchart presentation where appropriate• Data carries over to future pregnancies• Multiple GUI components planned• Flowchart infrastructure extensible to other
types of data
RPMS Behavioral Health SystemRPMS Behavioral Health System
• First complete electronic record in IHS (1990s)
• Graphical (GUI) version released 2003• Widely deployed throughout I/T/U system
– >250 sites
• Designed for A/SA, MH, and SW providers
• Integrated with RPMS medical information• Supports 3rd party billing for BH services
• First complete electronic record in IHS (1990s)
• Graphical (GUI) version released 2003• Widely deployed throughout I/T/U system
– >250 sites
• Designed for A/SA, MH, and SW providers
• Integrated with RPMS medical information• Supports 3rd party billing for BH services
RPMS Behavioral Health SystemRPMS Behavioral Health System
• Ability to document:– 1:1 patient encounters– Group encounters– Patient Education, Health Factors and screening
(depression, EtOH, DV)– Treatment Plans and Treatment Plan reviews– Case Management Information – Incidents of Suicide/Suicidal Behavior
• Ability to document:– 1:1 patient encounters– Group encounters– Patient Education, Health Factors and screening
(depression, EtOH, DV)– Treatment Plans and Treatment Plan reviews– Case Management Information – Incidents of Suicide/Suicidal Behavior
BH GUI ScreenshotBH GUI Screenshot
IBH ScreenshotIBH Screenshot
SRF ScreenshotSRF Screenshot
RPMS Case Management Applications
RPMS Case Management Applications
• Registry-based systems with reminders, performance indicators, and population-based reporting
• Immunizations• Diabetes Management System• Asthma Management System• Women’s Health• HIV Management System• Population Management (iCare)
• Registry-based systems with reminders, performance indicators, and population-based reporting
• Immunizations• Diabetes Management System• Asthma Management System• Women’s Health• HIV Management System• Population Management (iCare)
iCare Population Management GUI
iCare Population Management GUI
• Graphical interface for a fully integrated case management system
• Decision support and patient management for multiple chronic conditions
• Nationally defined preventive and disease-specific healthcare reminders
• Customizable patient panels• Quick performance views using CRS/GPRA
logic for any patient or group of patients• Plan to incorporate current and future disease-
specific register systems (DM, Asthma, HIV/STD, CVD, WH, etc.)
• Graphical interface for a fully integrated case management system
• Decision support and patient management for multiple chronic conditions
• Nationally defined preventive and disease-specific healthcare reminders
• Customizable patient panels• Quick performance views using CRS/GPRA
logic for any patient or group of patients• Plan to incorporate current and future disease-
specific register systems (DM, Asthma, HIV/STD, CVD, WH, etc.)
iCare provides the ability to create multiple, predefined and easy-to-define patient panels. Panels are customizable and unique to the individual user.
A Panel’s Patient ListA Panel’s Patient List
Modifying PanelsModifying PanelsModifying PanelsModifying Panels
Modifications made to individual panels affect that panel only
Users choosewhich columns they’dlike displayed and in what order.
Each panel can have a differentdesign
iCare utilizes logic written for other clinicalapplications to “tag” individuals with pre-defined diagnoses and conditions
““Tags”Tags”““Tags”Tags”
iCare displays patient “flags” related to •Abnormal labs •Hospitalizations •ER visits •Unanticipated ER returns
““Flags”Flags”““Flags”Flags”
Individual “GPRA” ViewIndividual “GPRA” ViewIndividual “GPRA” ViewIndividual “GPRA” View
User’s select which GPRA measures they’d like to view and then check to see if the measure is met for any individual patient on the panel.
Aggregated “GPRA” StatisticsAggregated “GPRA” StatisticsAggregated “GPRA” StatisticsAggregated “GPRA” Statistics
iCare uses “official” GPRA report logic on user-defined populations that are not currently available in the Clinical Reporting System (CRS)
Patient RecordPatient RecordPatient RecordPatient Record
iCare pulls all available patient data and displays it in one view
iCare will generate nationally-defined general prevention and disease/condition specific healthcare reminders that are integrated to display most stringent criteria applicable to the patient’s chronic condition(s)
CRS (Clinical Reporting System)
CRS (Clinical Reporting System)
• Automated reporting system for tracking over 300 clinical quality measures, including 22 GPRA measures
• Intended to eliminate the need for manual chart audits
• Available in both GUI and roll-and-scroll versions
• Awarded 2005 Nicholas E. Davies Award of Excellence in Public Health
• Automated reporting system for tracking over 300 clinical quality measures, including 22 GPRA measures
• Intended to eliminate the need for manual chart audits
• Available in both GUI and roll-and-scroll versions
• Awarded 2005 Nicholas E. Davies Award of Excellence in Public Health
CRS CRS • Identical logic ensures comparable
performance data across all facilities
• Updated annually to reflect changes in the logic descriptions and to add new measures
• Local facilities have the option of transmitting their data for most CRS reports to their Area Office for Area Aggregate Reports
• Identical logic ensures comparable performance data across all facilities
• Updated annually to reflect changes in the logic descriptions and to add new measures
• Local facilities have the option of transmitting their data for most CRS reports to their Area Office for Area Aggregate Reports
CRS 2007 Clinical MeasuresCRS 2007 Clinical Measures• 22 GPRA treatment and prevention measures• 23 other key clinical performance measure
topics. Examples:– Diabetes Comprehensive Care– Osteoporosis Screening– Comprehensive CVD-Related Assessment
• 22 HEDIS measure topics• 26 Elder Care measure topics (patients 55+)• 17 CMS (hospital) measures
• 22 GPRA treatment and prevention measures• 23 other key clinical performance measure
topics. Examples:– Diabetes Comprehensive Care– Osteoporosis Screening– Comprehensive CVD-Related Assessment
• 22 HEDIS measure topics• 26 Elder Care measure topics (patients 55+)• 17 CMS (hospital) measures
Sample Performance SummarySample Performance Summary
Quality Measurement in IHSQuality Measurement in IHS
• Sequist, et al. “Information Technology as a Tool to Improve the Quality of American Indian Health Care”, AJPH 95:12, Dec 2005
• http://www.ihs.gov/cio/crs/crs_performance_improvement_toolbox.asp
• http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/pe-gpra.asp
• http://www.ihs.gov/NonMedicalPrograms/BudgetFormulation/bf_cong_justifications.asp (see 2008 pp 202ff)
• Sequist, et al. “Information Technology as a Tool to Improve the Quality of American Indian Health Care”, AJPH 95:12, Dec 2005
• http://www.ihs.gov/cio/crs/crs_performance_improvement_toolbox.asp
• http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/pe-gpra.asp
• http://www.ihs.gov/NonMedicalPrograms/BudgetFormulation/bf_cong_justifications.asp (see 2008 pp 202ff)
Advantages of RPMSAdvantages of RPMS
• Software is GOTS – public domain - mostly• Flexible implementation (minimal to full)• Accommodates paper or electronic
documentation• Robust database with many standard reports
and powerful queries• Supports population health mission• Occupational Health module pending• Can use local or remote database
• Software is GOTS – public domain - mostly• Flexible implementation (minimal to full)• Accommodates paper or electronic
documentation• Robust database with many standard reports
and powerful queries• Supports population health mission• Occupational Health module pending• Can use local or remote database
Disadvantages of RPMSDisadvantages of RPMS
• Does not come with any support• Setup and maintenance of multiple
packages can be challenging• Not web based or enabled• EHR GUI requires separate
contract/license• EHR GUI requires setup of ancillary
packages (pharmacy, lab, radiology) that may not be used
• Does not come with any support• Setup and maintenance of multiple
packages can be challenging• Not web based or enabled• EHR GUI requires separate
contract/license• EHR GUI requires setup of ancillary
packages (pharmacy, lab, radiology) that may not be used
DiscussionDiscussion