using healthcare data to drive public health action - maryland...

Using Healthcare Data to

Drive Public Health Action

Joshua M. Sharfstein, M.D.

November 19, 2015

Background

© 2015/2016, Johns Hopkins University. All rights reserved.

Two Perspectives on Health

Clinical Medicine:

Care of the Patient

Population Health:

a Healthy Community


Hippocrates

• WHOEVER wishes to pursue properly the science of

medicine must proceed thus. First he ought to consider

what effects each season of the year can produce...The

next point is the hot winds and the cold, especially those

that are universal, but also those that are peculiar to each

particular region.

• He must consider … The mode of life also of the

inhabitants that is pleasing to them, whether they are

heavy drinkers, taking lunch, and inactive, or athletic,

industrious, eating much and drinking little.”

--Airs Waters Places http://daedalus.umkc.edu/hippocrates/HippocratesLoeb1/page.71.php?size=960x1280


Abraham Flexner

• The “intelligent and conscientious” physician should

endeavor “equally to heal the sick and to protect the well.”

• The physician has a duty to “promote social conditions

that conduce to physical well-being.”

-- A Medical Education in the United States and Canada, 1910


Two Ships Passing in the Night

Clinical Medicine

Insurance Coverage

Quality

Outcomes

Measurement

Public Health

Restaurant

Inspections

Lead Poisoning

Clean Air

Clean Water

Injury Prevention


AMA-APHA Initiative

• In 1995, a joint task force of the American Medical Association and

the American Public Health Association developed the Medicine and

Public Health Initiative, a project with the goal of closing the gap

between clinical care for the patient and the health of the population.

• The Robert Wood Johnson Foundation and the federal Agency for

Health Care Policy and Research funded 19 local initiatives, from the

reporting of infectious diseases in New York to the promoting of bike

helmet use in Seattle.

• However, although the effort “was embraced in some states and

localities, it was unable to bridge the cultural and institutional divide in

others.”

Beitch LM, Brooks RG, GlasserJH, Coble YD. The Medicine and Public Health Initiative: Ten Years Later.

American Journal of Preventive Medicine 2005; 29(2) 149-153.

The Times Change


Health Care = Too Expensive


Poor

Outcomes,

with Major

Disparities


Whose Progress in Health?

Source: National Academy of Sciences, September 2015


Losing Ground


Opportunity: Payment Reform

• Move away from fee-for-service reimbursement

• Align financial incentives of health care with better

community health

o Goal of 50% of Medicare payments through

alternative payment models by end of 2018

o “Whether you are a patient, a provider, a

business, a health plan, or a taxpayer, it is

in our common interest to build a health

care system that delivers better care,

spends health care dollars more wisely and

results in healthier people.”

-- Secretary Sylvia Burwell


Key Points

• Payment reform is necessary, but not sufficient, for

population health improvement.

• Health care organizations must think differently and

engage differently in order to successfully make use of

new incentives and contribute to overall health

improvement.

• To succeed, it’s helpful to understand the unique tools of

public health and what collaboration can add to the tools

of clinical medicine

The Tools of Public Health


664 INSTITUTE OF HYGIENE

IV. FIELD TO BE COVERED

The field covered by the terms "hygiene," "sanitary science," " public

health," "preventive medicine " is so broad and varied that it is hardly

pos-sible within a brief compass to indicate all of the subjects here

included. Strictly speaking the territory embraces a group of sciences or

the application of various underlying sciences. Unity is to be found

rather in the end to be accomplished --- the preservation and the

improvement of health--- than in the means essential to this end.It is the focussing (sic) upon this definite purpose which gives coherence

to the organized body of knowledge embraced under the designations

"hygiene" and "sanitation," and makes important its study and cultivation

as a professional pursuit.

Welch and Rose, 1915


Public Health

“What we as a society do collectively to assure the conditions in which people can be healthy.”

-- Institute of Medicine,1988

Photo: CDC


10 Core Functions of Public Health

Source: CDC


IOM, Healthy People 2010


CLINICAL VS PUBLIC HEALTH APPROACHES

Wang, Lancet, 2005

www.tco.gov.hk/english/quitting/quitting_pha.html


PREVALENCE OF HYPERTENSION

YI MEN, 1989

He et al. Am J Epidemiol 1991; 134:1085-1101

Migrants

Farmers


Infant Sleep-Related Deaths in

Baltimore

• Every baby received safe sleep onesie

• Every birthing facility counseled

• City wrote letters to nursery every time a baby died

• Yet … 27 infant deaths from unsafe sleep in 2009

Header/Full Bleed Image

Name/Subject Subhead

Title/caption

Title/caption


Advancing Population Health


3 Stages of Engagement

• Stage 1: Trying to do it all yourself

Care coordination

Clinical quality and prevention efforts

Home health

Health fairs and outreach

• Stage 2: Support work of others

Community benefits

Charitable giving


Stage 3: Leveraging Healthcare Data to

Reshape Efforts on Population Health

• Traditionally, public health data is based on vital statistics

or annual reviews of anonymized health data

o County Health Rankings

o America’s Health Rankings

• Data are infrequent, not local, and several months to

years old.

• Lack of relevant data has adverse consequences:

• Less understanding

• Less urgency

• Less engagement


Who Has Better Data? Healthcare.

Source: CDC, 2014


Thinking Outside the EHR

• First use of health care data is to improve clinical care

• Quality improvement

• Data sharing with other members of care team

• Second use of data can be to better understand

community health

• Mapping

• Combining with other data for insight and action

• Targeting interventions

• Rapid feedback

• Key is pivot from patient to community


Example: Infant Mortality

• Health care systems can

produce data rapidly on low

birthweight, prematurity,

inadequate prenatal care, and

other predictors of infant

mortality.

• Such data can be combined

with social service and

environmental data to support

local coalitions working to

improve outcomes for mothers

and babies

Source: Georgia DPH, 2012


Example:

Pneumonia


Reducing Pneumonia

• The public health department can assess vaccination

rates and access to primary care in hot-spot areas

• Initiatives to address pneumonia can receive rapid

feedback from healthcare data mapping


Example: Dental


Improving Oral Health

• Prevention and access to care initiatives can be targeted

to hot spot areas to reduce dental emergencies

• Healthcare organizations can set up systems to

automatically refer people in crisis for primary dental care

• Data from healthcare system can help assess impact of

these efforts rapidly


Example: Asthma


Improving Asthma

• In mid-2012, Meritus Health System in Hagerstown, Maryland took

over management of the school health system.

o 43 schools with 23,000 children

o 74 staff

• Initial priority: improve asthma management

o Training

o Identification of children without controller medications

• Further work can be done with more detailed mapping on

environmental contributors to asthma

o Goal: Identify asthma factories


Example: Overdose


Reducing Overdose

• Outreach to high risk areas

o Offering effective treatment, naloxone, and education

• Tracking measures short of fatalities

o ED visits

o Hospitalizations

• Intervening with ED visits to prevent overdose

Moving Forward


Value of Information Exchange


Big Picture• Healthcare data can make new

efforts to improve health possible and

successful

• Many diagnoses with intervention

points outside of health care are ripe

for engagement

• Beyond specific diagnoses:

preventable admissions, all

admissions, readmissions

• Collaborative efforts can be

organized across sectors to save

lives

Action

Results

Data


Considerations

• Working with competitors. Health systems should

consider seeking out other healthcare institutions in region

to compile truly population-based data. All benefit as

health is improved.

• Role of health information exchanges

• Working with public health. Together, assemble

coalitions to think creatively about all possible points of

intervention and improve population health


Why Now?

• Possible. New sources of data are just becoming

available to allow use for population health

• Financially advantageous. New incentives create

rewards for all involved for genuine community health

improvement

• Smart. Collaboration allows all tools – even those outside

clinical medicine – to support health improvement

• Innovative. New alliances and projects can try out

creative approaches to longstanding problems and see

quickly if they are promising


Acknowledgments

• Chesapeake Regional Information System for Our

Patients (CRISP)

• Jenner Alpern, Audacious Inquiry

• Center for Population Health Information Technology,

Johns Hopkins Bloomberg School of Public Health

• Joseph Ross, Jesus Cepero, and Amy Jones of Meritus

Health

• Dean Michael J. Klag

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