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Public Health Departments Using Advanced EMR/PHR Technology as a Means to Meet New and Expanding Challenges

by John Nelson, MPA¹; Theresa Green ,AA-C, MBA¹; Erin Edinger, MPH¹; June Moore, RN, MS ¹; Mara Boettcher, MS, MBA¹; Robin Henry, CFNP¹; John Kittredge, PA²; and Tom Jennings, MD²

¹Berrien County Health Department, Benton Harbor, MI 49022

²Medical Net Systems, 2824 South State St.,St. Joseph, MI 49085

Executive Summary

New and traditional challenges have made it necessary for public health departments to achieve more with less.  New technologies in online electronic medical records (EMR) and personal health records (PHR), such as EMR/PHR integration and adaptive expert questionnaires, are providing tools that the Public Health Department can use to meet these challenges.  This article discusses ways these technologies can be applied to:

• Disaster response, particularly the special needs population.

• Increasing access to health care for the citizens.

• Increasing the efficiency of the Public Health Department clinics.

• Improving the medical encounter of patients with high-risk behaviors.

• Epidemiological applications which identify community and individual’s public health needs as well as monitor disease outbreaks.

• Worksite wellness programs.

These initiatives would lead to improved public health and an increased profile for the public health department.

Coordinating disaster responses, increasing access to health care, providing public health clinics, dealing with high-risk behaviors are some of the traditional roles of the public health department.  In addition, the public health department is confronted with new challenges.  Public health departments must accomplish more with less to meet all these responsibilities. 

This paper will look at new challenges facing the 21^st century health department.  Then, we will examine specific technologies that are available now and how these technologies can be used to improve our public health.

Today’s public health departments are confronted with many wide and growing challenges.  These challenges include:

1. Portable and readily available medical records for its citizens.  After Hurricane Katrina, this has have been identified as an important need.

2. The increasing number of the uninsured or poorly insured citizens. The rising cost of health care has increased the number of uninsured or poorly insured citizens.  Many are not receiving even the minimum preventive health care, though preventive health care has been shown to be life-saving.  Also, such patients are increasingly using federally funded clinics.

3. The obesity epidemic. With up to 2/3 of adults being overweight and an explosion of childhood obesity, the number of citizens at risk or with chronic diseases, such as hypertension and diabetes, is staggering.  Health care organizations are designed to treat disease not prevent disease; in fact, effective disease prevention would hurt a health care system’s bottom line.  Yet from society’s perspective, treating disease is the most expensive and most inefficient means of promoting health.

4. Overall community health as a component of economic development.  As health care costs rise and become a significant part of an employee’s benefit package, the community’s health care costs have become a significant factor in a business’s bottom line and decision where to locate. Improving a community’s health and its health care system’s efficiency is now an important component in a community’s competitiveness in the global competition for jobs and industry.  Both Ford and GM have pointed to the rising health care costs as a major reason for their recent losses.  It has become clear that: Good public health is good business.

5. Disease outbreaks.  With a growing, increasingly mobile population and bioterrorism remaining a real threat, public health departments must have new, more efficient means to monitor outbreaks and rapidly gather and identify the causes of these outbreaks.

New Technologies: The Advance Integrated EMR/PHR

Electronic medical records (EMRs) are a digital version of a physician’s chart.  Patient health records (PHR) are records of patients’ medical histories that is created and maintained by the patient.  This record is not tied to one physician or group of physicians, but rather travels with the patient.  Recent advances in the electronic medical record and personal health record technology has provided a means for public health departments to meet these challenges and opportunities to improve their services.  These advances include:

1. EMR/PHR integration.  Integration of the EMR and the PHR has many powerful implications for health care.  For this integration to occur, the EMR and PHR need to have the same data structure.  An integrated EMR/PHR means that a patient can complete his or her medical history in the PHR, then import it into the health care provider’s (HCP) EMR.  This gives the HCP instant access to the latest information on the patient with minimal effort.  During the patient visit, the HCP can edit and append patient history, and then, at the end of the visit, the EMR will simultaneously update the PHR data.

This process repeats itself every time the patient sees another HCP; the PHR is updated and integrated with each of the HCP’s EMRs.  This creates a community health record linking all the patient’s health needs with appropriate community resources.

The following illustration shows how this integration works.

Figure 1.  EMR/PHR integration.  Each patient visit or interaction updates the PHR.

2. Web-based EMR/PHR.  Since it is on the web, a patient’s record with password and security protection is available virtually anywhere any time.  Secure Socket Layer (SSL) security is the same security used in online credit card transactions.  The PHR is available in the emergency room, the hospital, various physician offices, etc. The integrated PHR/EMR is the community health record linking the patient with appropriate health services.    

Figure 2.  The patient’s record is available virtually anywhere anytime. 

3. The EMR/PHR uses discrete data elements and diagnostic equivalence techniques that facilitate epidemiological analyses.  Surprisingly, previous EMRs could not provide epidemiological data because the data structure was not discrete and consistent across sites as physicians often use different terminologies to describe the same disease process.  The advanced integrated PHR/EMR can provide much-needed epidemiological data because the history and physical exam data is consistent and discrete.  Also, all diagnostic terminology has been rendered equivalent by a technique known as diagnostic equivalence.  For example, if two HCPs label the same disease differently i.e., hypertension and high blood pressure, it is difficult to realize that the two labels are referring to the same disease entity and group them together.  With diagnostic equivalency, the two terms are treated as one disease. 

Figures 3 and 4 show an example of reports from the patient history. These reports can not only gather epidemiological population data but can also identify individual patients who need intervention.

Figure 3. Report Showing How Many Patients Made a Particular Response

Figure 4. Report Listing Individual Patients Who Made a Specific Response and in this case, because the response was a fill-in, the responses were made. (Patient demographics are de-identified)

4. Application of Adaptive Expert Questionnaire technology to the medical history.  Patients are asked appropriate questions based on their responses.  Thus patients are only asked relevant follow-up questions.  An adaptive expert questionnaire produces a customized medical questionnaire for each patient. Compare how information about smoking is obtained in a paper questionnaire versus an adaptive expert questionnaire.  

Figure 5. Paper Questionnaire:  One answer with the ambiguity of what exactly the patient is saying yes to... cigarettes, cigars, snuff, or chew tobacco.

 Figure 6. These questions are asked by the adaptive expert questionnaire only if a patient says yes to smoking.  (Note these questions are presented to the patient one at a time.)

The adaptive expert questionnaire enables patients to complete comprehensive medical histories and transfers the workload of taking a medical history from the HCP to the patient, resulting in  tremendous time savings for the HCP.  Because the patients are able to create their own medical histories, the ideal of having each member of the community possess a comprehensive personal health record is feasible.  Also studies show that patients are more open and honest answering questions on a computer.

5. The Client Expert Module.  This module allows public health departments to create their own specific adaptive expert questionnaires.  Such questionnaires could be created for:

• Public health surveys – questions concerning the specific circumstances surrounding a disease outbreak.
• Clinical trials.
• Specialty clinics.

What follows is a description of how these technologies can help a public health department meet these challenges.

Disaster Response

Public health departments have two main responsibilities in disasters.

1. Coordinate the response to emergency disasters.  The public health department, using an advanced integrated PHR/EMR, can improve their response in several ways:

1. First responders could provide better, more efficient care: If paramedics and emergency physicians had their patients’ medical history and medication list, they could provide better care more quickly since they would not have to obtain a medical history.

2. Continuity of medical care after post-Katrina-like disasters: If some disaster destroyed the regional infrastructure, an online medical EMR/PHR would enable continuity of care for residents.  EMR/PHR data would reside on servers throughout the country insuring data redundancy and therefore availability.

   Additionally patients would have a mobile record that would accompany them from physician to physician.  Individual patients would have a record that they could give to all their physicians.  This common record would improve the patient’s medical care and improve the efficiency and quality of his or her care.

2. The public health department has even greater responsibilities for the local special-needs population.  This population includes hearing impaired, vision impaired, non-English speakers, homeless, etc. These responsibilities include:
   1. Identifying these patients.

   2. Notifying these patients of an evacuation.

   3. Assuring transportation/evacuation.  This means transportation requirements, given a patient’s special medical conditions, must be identified a priori.

   4. Continuing delivery of needed health/medical care. There must be continuity of medical care for these special-needs patients in the event of an evacuation.  Specific equipment and facility requirements for each special-needs patient must be identified.  Special-needs patients must be sent to locations where the appropriate medical equipment and facilities are available.

The advanced integrated PHR/EMR can collect data to allow identification of special-needs patients and their medical needs.  The reporting system can create: reports listing the patients and their needs; and follow-up reports to periodically check on these patients to see if their circumstances and/or needs have changed.  These special-needs questions can be created in the client expert module.

Increasing the Access of Its Citizens to Health Care

The advanced integrated PHR/EMR can achieve this through the post PHR summary report.   After completing the PHRs, patients can view reports and action sheet created through on their responses.  Then they can immediately act on the findings/suggestions.  These suggestions would include making appointments for: medical exams, counseling, smoke enders, weight loss/nutrition clinics, etc.  Links to online appointment systems for the various clinics, information sheets downloads, and links to the videos could be part of the report.  These videos could include informational videos about diseases, wellness, testimonies of former addicts, etc.  The public health department could approach the local cable company and ask if it would be willing to have a free section of its on-demand video section for these videos.

To further increase health care access for more citizens, the PHR could be written in other languages.  The patient’s text responses could be translated by computerized translation functions.

Increasing the Efficiency of Public Health Department Clinics

With the increasing number of uninsured and poorly insured, public health department services are under increasing pressures to do more with less.

The advanced integrated PHR/EMR would help increase the efficiency and quality of care.  Much of the workload of gathering histories would be transferred to the patients. Patients seen at multiple clinics would have their update medical records available at all their medical visits.  Miscommunication, testing duplication, and treatments working at cross purposes would be obviated.   During patient encounters, the HCP is no longer interrogating patients but rather is counseling patients based on the patients' responses.

Treatment Favorites are a means for an HCP to make a complex series of orders with just a click.  Once inserted into the EMR, these orders can be modified.  Treatment Favorites are a way for insuring that treatment protocols are standardized and followed by HPC across clinics and at the same time giving HCP discretion to change orders as necessary.    

Diagnostic equivalence allows the advanced integrated EMR/PHR to prospectively inform HCP that the patient they are presently seeing is eligible for a clinical trial or fulfills the criteria for best-practices guidelines.

Dealing with Patients with High Risk Behaviors

Public health department clinics, such as the venereal disease clinic, and drug/alcohol abuse clinics need to address patients’ high-risk behavior. 

The advanced integrated PHR/EMR enhances encounters with high-risk-behavior patients in several ways. 

• In Patient Generated Medical History, either in the EMR or the PHR, the patient is asked a series of questions about high risk behavior.  The questions include a list of problems caused by these behaviors, starting a self-actualization process for the patient.  Patient Generated Medical History also asks if the patient has tried to change his or her behavior in the past and if they are interested changing now. Studies have shown that the patients are much more candid answering questions from a computer than from a person.   

• When the patient is finishing the PHR, in the final report, the patient can be offered a link to make an appointment with one of the abuse clinics described above. 

• When a high-risk-behavior patient is seen in either a general clinic or in a high-risk clinic, the HCP can read the patient’s responses prior to seeing the patient and determine the patient’s motivational status. Then, during the encounter, the HCP can use the patient’s own responses when counseling the patient about the high-risk behavior.  This is a very effective technique for motivating positive change. 

• When patients are performing the Patient Generated Medical History, they can be given links to online presentations, describing the consequences of the high risk behavior with animation and testimonials by people who had those high-risk behaviors.  Education is part of the process that convinces a patient with high-risk behavior to change. 

The Client Expert Module enables the clinics to fashion the appropriate questions concerning a particular behavior and distribute them across sites. 

Epidemiological Applications: Identifying the Public Health Needs
of the Community and the Individual

The first step in addressing the community’s health care needs is to identify what they are.  With the advanced integrated PHR/EMR, reports can create the population data and, in the same reports, identify those patients at risk and needing further intervention.  Through the review and analysis of this valuable information, a sense of the public’s health needs can be determined.  As such, the department will have some information on what to prioritize as health needs -- for whatever population has completed the PHR.

By placing the advanced integrated EMR at various clinics throughout the region, the public health department, using the reports described above, can perform real-time disease surveillance of its region.

Disease Outbreaks

Online adaptive expert questionnaire surveys attempting to identify the source of food-borne and other disease outbreaks could be developed using the client expert module.  Reports summarizing the responses and identifying specific factors could then be created. 

Worksite Wellness

The public health department could offer a wellness program to area businesses.  Using the advanced integrated PHR/EMR as part of the package, the health department, through the reports and reporting described above, would be able to identify employee health needs and offer solutions.

These wellness programs would be beneficial to all participants:

• Businesses would have healthier employees, reducing work days lost, and depending on the health insurance they offer their employees, reduced health costs.   Businesses would be showing concern for their employees.  This has been shown to result in increased employee productivity and loyalty.

• The advanced integrated PHR/EMR could be the conduit for a business’s prescription plan.  The employee’s HCP provider could write the PHR patient prescriptions through the PHR.  This would accomplish 3 things. 
  • It would be another service the health department could offer in its wellness program to businesses. 

  • It would insure a current medication list for the patient, a very important thing for quality health care.

  • It would give businesses a strong negotiation point with the pharmacy benefit provider, i.e., all prescriptions are in an electronic format that providers desire, hence facilitating prescription filling.

• The wellness program could be a profit center for the public health department and would raise its profile in the community.

• The wellness program could be a marketing point for the region to attract new businesses.  The region’s economic development corporation could point to this program to businesses contemplating locating in the area it would demonstrate the area’s commitment to wellness and reducing health care costs and would be a program that they could participate.

Increasing the Profile of the Public Health Department

Getting the public to participate and utilize the PHR will require enlisting the community in the effort. Through these efforts, a culture emphasizing wellness will be initiated across the county.

Since completing the PHR does not require much medical or computer expertise, people with very little training could assist patients unable to complete the PHR.  This outreach would include going to area businesses, churches and other groups and asking for volunteers to assist other citizens in the completion of the PHR.  People assisting others completing a PHR could include low-skilled workers, people fulfilling community service requirements, high school students, etc.  For some of these people, helping patients completing their PHR, might be a life-changing experience.

All these efforts would raise the profile of the public health department.

Summary

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