How Public Health Can Appear Inside an EHR

How Public Health Can Appear Inside an EHR K.D. Pool, MD Terese Finitzo, PhD

Public Health and The EHR • Why would we want to be “inside”? • How could we get “inside”? • Who’s in control? • Why not? • Now what can we do?

Forms • Why do we love them? • We can create a form that gathers all of the data we need for a topic. • We can change them. • They meet the needs of the agency that needs data.

Forms • Do providers love forms? • Not so much. • They are not fun to fill out. • They take time away from doing whatever it is that providers do when they are not filling out forms.

EHR • A place to record point-of-care data. • Organized around a patient. • Designed to make it easy to document and review data about a patient. • They are becoming ubiquitous. • This is where providers “work”.

Interoperability • Send data from one system to another. • Standardized processes so the sender and the receiver both know how to make the exchange. • Standardized structured data so the receiver knows something about the data it receives.

Landscape • Forms == data related to a topic that I need from the provider at the point-of-care. • EHR == place where provider records point-of-care data. • Interoperability == way to move data

Landscape • So we just specify the data we need based on interoperability content standards; • The EHR can then pull out the data and package it up and send it to us; and • We receive the data and go do our job.

Landscape • We get the data we need; • Provider doesn’t have to spend time filling out a form; • Life is good…. • So what is the hold up here?

Interoperability • Send data from one system to another. • Standardized processes so the sender and the receiver both know how to make the exchange. • Standardized STRUCTURED data so the receiver knows something about the data it receives.

Structured Data • Not all data in an EHR is structured. • Not all data needed by public health forms is structured. • So we can’t exchange reliably. • SO JUST WRITE A NEW STANDARD.

Structured Data Standards • The nuisance about standards is we have to agree on them or at the very least tell people what they are. • Developing a new standard is not easy and not fast. • THEN THEY HAVE TO BE IMPLEMENTED. • And then if we need to change we start over.

Structured Data Standards • It can take 1-2 years to develop a new standard (getting shorter). • Current standards implementation backlog for many EHR systems is measured in years. • Not everyone will implement our standard.

Back to the drawing board… • Paper Forms • Create the form • Print and distribute it • Fill it out • Ship it back • Transcribe the data

Back to the drawing board… • Web forms • Create the form • Put it on our website • Fill it out • Form sends us the data the way we need it

Web Forms beat Paper Forms • Deployment – saves trees (and dollars) • Deployment – provider doesn’t have to keep a stash of forms (nor do we) • Version–change in version is instantaneous • Data - we don’t have to transcribe to get data

Web Forms: The dark side • Even though a lot of the data we need is in the EHR as structured data providers have to re-enter those data into our form. • Providers have to “go to” our website (giving them an excuse not to report).

What if? • Could get benefits of web form AND • Be able also get the data from the EHR that is structured AND • Be “inside” the EHR so the provider doesn’t have to go to our web site. • THAT IS RFD.

RFD • Is a web form that appears “inside” the EHR • Can be updated and deployed at will • Can get the data for our program electronically • Can “use” the structured data that is in the EHR.

RFD? • Retrieve • Form for • Data Capture • IHE Standard • Originally developed by CDISC

RFD: What are the parts? • Form Filler • Form Manager • Form Receiver • Form Archiver • Form • User

RFD: How does it work? 2 Form Manager 1 Form Filler 3 User 4 5 6 FORM Form Receiver 6 Form Archiver

RFD: OMG! 2 Form Manager 1 Form Filler 3 User 4 5 6 FORM Form Receiver 6 Form Archiver

RFD: One step at a time Form Manager Clicks button Form Filler User FORM Form Receiver Form Archiver

RFD: One step at a time Builds document with structured data Form Manager Form Filler User FORM Form Receiver Form Archiver

RFD: One step at a time Sends document and which form is needed Form Manager Form Filler User FORM Form Receiver Form Archiver

RFD: One step at a time Gets current version of form Form Manager Form Filler User FORM Form Receiver Form Archiver

RFD: One step at a time Reads document with structured data Form Manager Form Filler User FORM Form Receiver Form Archiver

RFD: One step at a time Fills in form data from document data Form Manager Form Filler User FORM Form Receiver Form Archiver

RFD: One step at a time Form Manager Form Filler Returns web form with filled in data User FORM Form Receiver Form Archiver

RFD: One step at a time Form Manager Form Filler User Displays form for user FORM Form Receiver Form Archiver

RFD: One step at a time Form Manager Form Filler User Fills in remaining data FORM Form Receiver Form Archiver

RFD: One step at a time Form Manager Form Filler User FORM Clicks SUBMIT Form Receiver Form Archiver

RFD: One step at a time Form Manager Form Filler User FORM Form Receiver Gets data entered and sends it to archiver Form Archiver

RFD: One step at a time Form Manager Form Filler User FORM Form Receiver Form Archiver Gets data and puts it in the archive

RFD: One step at a time Form Manager Form Filler User Gets data entered and sends it to receiver FORM Form Receiver Form Archiver

RFD: One step at a time Form Manager Form Filler User FORM Form Receiver Gets data and…. Form Archiver

RFD: Form Filler (think EHR) • Generates standard document with structured data (they know how to do this) • Sends that document to Form Manager along with a request for form X (easy to implement and doesn’t matter what form is being requested). • Display web form (think browser window)

RFD: Form Filler Key Features • Does essentially the same thing no matter what the form is. • Once an EHR has implemented RFD it can support virtually any form and virtually any number of forms. • Which means when we add or change a form we don’t have to wait for the EHR to implement the change.

RFD: Form Manager • “Brains” of the process to capture the data. • Manages the structured data associations between the EHR data and the form data. • “Absorbs” the impact of changes. It is built to support change. • Virtually unlimited potential for what a smart manager might do.

RFD: Form Archiver • Pristine place to record what was entered in the form. • Meant to be a “read only” copy.

RFD: Form Archiver • Smart archivers can show • What was “pre-filled” and left untouched • What was “pre-filled” but user changed • What was added by the user • What the form looked like

RFD: Form Receiver • By standard not very impressive • Just receives the data • This allows it to be very flexible

RFD: Form Receiver + • Power is in what is done next with the data • Use the data to “build” a document • Save the data into a repository • Restructure the data to match what the public health system is capable of

RFD: Form Receiver + • Can be a distributor • Can send the data to more than one “consumer” • Meaning multiple public health programs can each get their own copy of the data in the way they need it • Can “batch” up data or send in real time

RFD: Who is in charge here? • Form Authority • This is whoever will ultimately get the data • Controls what data are in the form • Controls what the form looks like • Controls what the form does

RFD: Who is in charge here? • Form Authority • Controls how structured data from the EHR is used to “pre-fill” the form • Controls who gets the form data • Controls how the form data are delivered • DOES NOT HAVE TO BE THE MANAGER TO BE IN CONTROL

RFD: Who is in charge? • Form Filler • Controls what forms can be selected by the user • Controls when forms can be selected • Controls what data are “disclosed” to “pre-fill” the form • Controls the use of an archive

RFD: Who is in charge? • User • Controls what data are entered and sent

RFD: Who is in charge? • Form Manager • Controls which forms are supported • Controls which user/EHR can access what form • Otherwise it just follows instructions

How Public Health Can Appear Inside an EHR