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Howard Hays, MD, MSPH RPMS Program Manager, IHS. World VistA Community June 16, 2007. Indian Health Service. Provides comprehensive care to over 1.6 million American Indians / Alaska Natives Nearly 600 health care facilities Federal Tribal Hospitals 36 13

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Howard hays md msph rpms program manager ihs

Howard Hays, MD, MSPH

RPMS Program Manager, IHS

World VistA Community

June 16, 2007


Indian health service
Indian Health Service

  • Provides comprehensive care to over 1.6 million American Indians / Alaska Natives

  • Nearly 600 health care facilities

    Federal 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 service1
Indian 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)


Data needs
Data 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.


Data issues in ihs
Data 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.


RPMS

  • Resource and Patient Management System

  • IHS Health Information Solution since 1984

    ---- A.K.A. ----

    Really Powerful at Measuring Stuff


What is rpms
What is 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


Vista and rpms
VistA 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


Ihs is not vha
IHS 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


Rpms integrates multiple clinical systems
RPMS Integrates MultipleClinical Systems


The ehr challenge for ihs
The 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


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 . . .

Lacking elements

Provider order entry

Note authoring

Point of care data entry

GUI usability

Active reminders & notifications

RPMS – Elements of an EHR for over 20 Years


Rpms electronic health record
RPMS 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





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


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


Ihs specific ehr components
IHS-Specific EHR Components

  • Medication management interface

  • Immunizations

  • Patient Education

  • Problem List

  • Diagnosis entry and coding

  • Superbills and CPT coding

  • Numerous others


Other rpms capabilities
Other 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)


Immunization data exchange
Immunization 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


Reference lab interface
Reference 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


Well child care
Well 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)


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


Rpms behavioral health system
RPMS 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


Rpms behavioral health system1
RPMS 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                 





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)


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.)


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 List and easy-to-define patient panels. Panels are customizable and unique to the individual user.


Modifying panels
Modifying Panels and easy-to-define patient panels. Panels are customizable and unique to the individual user.

Modifications made

to individual panels

affect that panel

only

Users choose

which columns they’d

like displayed and in

what order.

Each panel can

have a different

design


“Tags” and easy-to-define patient panels. Panels are customizable and unique to the individual user.

iCare utilizes logic

written for other clinical

applications to “tag”

individuals with pre-

defined diagnoses and

conditions


Flags
“Flags” and easy-to-define patient panels. Panels are customizable and unique to the individual user.

  • iCare displays patient “flags” related to

    • Abnormal labs

    • Hospitalizations

    • ER visits

    • Unanticipated ER returns


Individual gpra view
Individual “GPRA” View and easy-to-define patient panels. Panels are customizable and unique to the individual user.

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 statistics
Aggregated “GPRA” Statistics and easy-to-define patient panels. Panels are customizable and unique to the individual user.

iCare uses

“official” GPRA

report logic on

user-defined

populations that

are not currently

available in the

Clinical Reporting

System (CRS)


Patient record
Patient Record and easy-to-define patient panels. Panels are customizable and unique to the individual user.

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 and (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


CRS and

  • 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 measures
CRS 2007 Clinical Measures and

  • 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



Quality measurement in ihs
Quality Measurement in IHS and

  • 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 rpms
Advantages of RPMS and

  • 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 rpms
Disadvantages of RPMS and

  • 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



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