Big Data: Compiling Data

Across EHRsTim Burdick MD MBA MSc

Assistant Professor

Geisel School of Medicine

Community and Family Medicine

Biomedical Data Science

The Dartmouth Institute

Dartmouth-Hitchcock Health

Primary Care Clinic

Heater Road

Lebanon, NH

Nothing to disclose.

Forget the stethoscope, kid. It’s all about EHR data!

Does he expect

me to document

the exam in the

computer?!

Where are we going today?

Why digitize medical records?

EHRs under the hood

Linking data in PBRNs

Projects in PBRNs

The future of truly big data

Discussion

Always start with the WHY?

Why make information electronic?

Carpenter & Canaday (2004)

ENVIRONMENT

• This is our patient, Fred

• Measure; create structure; codify

DATA

• Fred: HA1C = 7.8;BMI = 38

• Look for patterns; understand relationships

INFORMATION

• Fred has Type 2 diabetes caused by his obesity

• Understand patterns; find predictability

KNOWLEDGE

• Patients w/ DM have lower quality life years & cost more

• Apply patterns; understand principles/goals

WISDOM

• DM guidelines improve Quadruple Aim outcomes

• Use compassion; apply values

VISION

• Effective treatment of patients with DM is good for all

CONTEXT/

RULES

MEANING/

MODEL

INSIGHT

VALUE/

PURPOSE

INDEX

Environment

Data

Information

Knowledge

Wisdom

Vision

PAST

FUTURE

Environment to Vision

The Bad and The Ugly

ANNALS OF MEDICINE NOVEMBER 12, 2018 ISSUE

WHY DOCTORS HATE

THEIR COMPUTERSDigitization promises to make medical care easier and

more efficient. But are screens coming between doctors

and patients?

By Atul Gawande

And the Good

https://www.opennotes.org/

Choosing Wisely Clinical Decision Support Adherence and

Associated Inpatient Outcomes

26,500 inpatient encounter measured adherence to CDS

- Cost of care 7% lower

- Length of stay 6% lower

Millions of patients worldwide

- 83% report feeling more more in control of their health

- 25% report a correction to their medical record

Heekin et al. Am J Manag Care. 2018;24(8):361-366

In the Beginning there was...who is this man?

Lawrence L. Weed MD

UVM College of Medicine

Professor of Medicine, and Community Medicine,

Director, PROMIS Laboratory

(Problem Oriented Medical Information System)

Touchscreen of the

Megadata Terminal.

c. 1977

Grand Isle Clinic, VT – PROMIS (c. 1979)

Microwave dish

Health Insurance Portability and Accountability Act (1996)

Title II: Administrative Simplification Provisions

● Implemented 2005 for claims submissions

● Standard electronic codes for encounters (ICD-9, ICD-10)

● Standard data transmission methods

● Security requirements

● National Provider Identification (NPI)

HIPAA, not HIPPA (a female hippo?)

What drove $36 billion dollar investment in health IT?

The US Housing Market

And the US economy generally

American Reinvestment & Recovery Act (ARRA) 2009

Healthcare Information Technology for Econonomic and Clinical Health (HITECH)

● Federal government reimburses hospitals and physicians for EHR adoption

● Must demonstrate “Meaningful Use” of the EHR

● Incremental requirements each year

● Clicking for dollars

Standards

● ICD – International Classification of Diseases (1900)

● SNOMED CT – Systematized Nomenclature of

Medicine Clinical Terms (1965)

● LOINC – Logical Observation Identifiers Names and

Codes (1994)

● RxNorm (2001)

RxNorm for codeine 30mg tablet:

SNOMED for scalding of the left index finger

C0123456|Codeine|Codeine Phosphate|Codeine|P|30|MG|Component

Common Data Models (CDM)

Enter heart rate in EHR user interface

EHR stores in database tables

Database Extraction, Transformation, Load (ETL)

• identify what data to pull out of EHR tables

• map to Observational Medical Outcomes Project

(OMOP) data model

• merge data from multiple EHR into combine database

with CDM

MRN VS_Date VS_time VS_measure_source VS_value

34823948-1 2020_01_24 0819 HR_monitor 92

40294820-3 2019_11_12 2354 SBP_left_arm 135

93092835-7 2018_07_15 1343 DBP_right_arm 82

83458230-7 2017_10_28 1005 Ox_Sat_finger 91

00299128-4 2019_08_01 1739 wt_kg_bed 78

MRN Name_Last Name_First DOB Zip_Home

83458230-7 Flintstone Fred 457_BC 99731

34823948-1 Flintstone Wilma 462_BC 99731

93092835-7 Burdick Tim 1981 03755

Functional Assessments

- Standardization

- Paper forms

- Manual data extraction & entry

- Subsample of patients or charts

- Data sizes in the hundreds

- Time-intensive

Dartmouth Coop

Charts

Then

Dartmouth Coop

Charts

Now

LOINC codes

● Formerly Oregon Community Health Information Network

● 1 shared EHR (Epic) since 2000

● 500+ organization partners

○ > 100 FQHCs

● 47 states

● >10,000 providers

● > 500,000 unique patients per month

● >400 staff in 35 states

● Teach and lead clinical quality improvement to member organizations

● $53 Million in external research dollars

● Hundreds of peer-review publications in top journals

PCORI CDRNs● 9 clinical research data networks

● Regional aggregation of core data from

many EHR systems

● EHR, Claims, Social Determinants,

Geocoded, Patient Reported Outcomes,

Insurance status, pharmacy dispense, test

results, immunization registries

pcornet: meta-network

66 million patients

550 million encounters

6 billion lab results

1 billion prescription dispenses

ADVANCE CDRN

- OCHIN-affiliated clinics

- Fenway Health clinics

- Oregon Health & Science University clinics

pcornet projects

● Do antibiotics in early childhood

increase risk of obesity?

○ 700,000 children

○ 10-year longitudinal study

● Sleeve gastrectomy is safer than

Roux-en-Y gastric bypass (RYGB)

○ 33,000 patients

○ 5-year study

States with PCORI Rare Disease Project leads

DARTNet (Distributed Ambulatory Research in Therapeutics Network)

Started 2007 (AAFP, Univ Colorado Family

Medicine, AHRQ, private tech company)

Developed ELT tools for any EHR

Map data to OMOP CDM

12 PBRNs contracted services

3 rural: WWAMI, Appalachian, Upstate NY

Value-add services

Quality improvement analytics and reports

Meaningful Use /PIP registries

● 5 million patients

● 12 million encounter per year

● 5 billion data points

DARTNet Academic Partners

•Northwestern University•Ohio State University•University of Alabama at Birmingham•University at Buffalo•University of California San Diego•University of Colorado Denver•University of Kansas•University of Minnesota•University of Texas San Antonio•University of Vermont•University of Washington

Academic Partners

NIH Clinical Translational Science Award centers

(~ Dartmouth Synergy)

© Epic Systems, Verona, WI

Single Alcohol Screening Question

● 77 weeks of data

● 200+ clinics

● 95,537 screenings

● 24.5 million visits

● Now you have data

about alcohol use

patterns across

large population

Correlate w use of

services, chronic

disease, mental

health, etc

Big, Really Big Data

Genomics

Imaging studies (MR, pathology)

Social Determinants

Exposome

Proteome

Microbiome genetics

Wearables and implantables

Discussion

What EHRs are you using? (Poll)

eCW? Epic? athenahealth? Allscripts? Amazing Charts? Greenway?

NextGen? Cerner? Other?

How are you leveraging data for quality improvement in your practice?

Research studies using your practice data from EHR?

What is keeping you from using your data more effectively?