Participants in southeast Minnesota’s PHDoc electronic record system have been exchanging health information for 25 years - longer, perhaps, than the acronym HIE or the ideology as we now know it have even existed.

What started when the state opted to stop supporting the information system used by local public health agencies became PHDoc. It still stands today. And, in fact, is the foundation of work the group is doing with Beacon grant funding.

Government Health IT Editor Tom Sullivan spoke with one of the driving forces behind PHDoc, Daniel Jensen, Olmsted County’s associate public health director about injecting PHDoc with NwHIN protocols such as Connect, to enable local public health entities to interact with and support not only each other, but also private providers - and patients above all.

Q: To start, I ought to ask, exactly what is PHDOc?
A: PHDoc is a public health documentation system; that’s what it stands for. It allows us to document very specific client interventions that occur with local public health clients that we see. Whether that’s maternal child health for newborns, or working with pregnant mothers in their environment. Whether it’s case-managing or care-coordinating for the elderly to deal with issues they face in their home environment to connect them with a broader set of services that allow them to stay more independent within the community, or working with specific medical providers. We are able to do electronic billing, electronically sharing information around immunizations, and because of the work that we did to build this platform, we were able to secure a Beacon grant and we are in the process of standing up a NwHIN Connect infrastructure that will allow us to exchange Continuity of Care Documents, other CDA (Clinical Document Architecture) documents, take an HL7 ADT feed and put that off the CDR (Clinical Data Repository) that we’re utilizing for the Beacon project. So we are very close to implementing these.

Q: So, how do all those pieces fit together?
A: ONC came and did a site visit and we were able to show a demonstration where Winona Health Systems, one of the medical partners in this, could trade a test CCD document. PHDoc was able to request that CCD file, receive it, consume it, lay a Style Sheet on top of it, save it as a PDF that showed the discharge claim wrapped around that fictitious client and - at the same time we were able to parse all of the client’s medications - bring that into a section of PHDoc that showed it as a medication list on the left-hand side. We were able to drag over certain medications to the right side and turn it from a medication list to a medication reconciliation. Then we could show additional medications that may not show up in a regular discharge document, such as over-the-counters. Then we’d be able to push that out to a lab service that will allow us to view drug-to-drug interactions against that medication-reconciled list. So those are some of the early places that we’re going with HIE-type work within our systems that are probably fairly common to what you’re going to see. What’s unique is the fairly small platform on which we’re able to accomplish that work.

[Q&A: Taking a radiology practice from no IT to HIE -- with ROI.]

So all those things are similar to what you’d find in an EMR but, again, using a focus and methodology that’s very specific to public health. We also can do things around community outreach, population and policy development that we can track over time. Those types of things are very specific and somewhat unique to local public health agencies, and are just built into the system and really aren’t available in most of today’s EMR systems.

Q: It’s pretty clear how that benefits patients, but how might all this, in turn, help the providers?
A: We’re working with this community of practice across southeast Minnesota, public health agencies working together on this Beacon grant with private providers, so we’re able to bring to the table the community point-of-view that has not been made available to physicians in other types of work that they’re doing. For example, one of the things we’re working on developing as part of the Beacon grant is to provide a listing of all our active clients and the associated public health nurse, the associated social worker, on that person’s case to those people who are case managing in maternal child health and adult disabled populations. That list will be available to the medical provider electronically. They will be able to embed that into their system, and then when the person is admitted into the hospital, it will compare that person’s name against our list and if there’s a match we’ll receive a notification indicating that one of the clients has just been hospitalized. We’re going to be able go in and work with that hospital to provide the community-based perspective that they may not get looking at lab results and working with their normal environment.

An example of something that happened probably about two months ago was that we had a client who was hospitalized and we found out in a roundabout way. But the nurse went in to work with the physician and instead of discharging that person to an assisted-living facility that lacked the ability to deal with that person’s emerging dementia issues, we had that person go to a place that did have capability to handle those dementia issues that the physician wasn’t able to diagnose at a normal hospital visit, but the public health nurse was aware of. It was early onset, early enough that it wasn’t being picked up in other arenas, but the public health nurse knew about it from working with the family.

Q: So when you’re aligning these different public and private health entities, is the model starting to look a little like an ACO?
A: Our goal really is to make sure that local public health is able to have a voice at the table because as we deal with the medical providers, there are a significant number of issues that they’re having to deal with. There’s an issue around discharge that if a person is readmitted to the hospital within a relatively short period of time, then they stand to lose reimbursement for those types of services. The local public health and the work we do with keeping clients and individuals independent, there is a community-based perspective that we believe we bring to that discussion when we’re able to be involved in that practice, step up to the table and work together on those types of services. We’ve done that in several ways in the past but maybe not as coordinated as it could have been. And now I think we’re moving in a new direction, into a new realm where we can really have that voice at the table and find a relevant way to improve the workflows and move that into an electronic mechanism.

Q: Now that CMS came out with the ACO final rule, is that something you’ve considered, actually becoming an ACO?
A: As a Beacon community of practice, we really have such a short time frame that we’ve been required to move forward with as fast as we’re able to move and so some of the things that we’ve had to work on and develop are the direction that we see things moving as the specifics come into place. As we see these things roll out, we’re definitely going back and reevaluating what our positions are to see if we need any mid-course directional changes or if we’re on the right track with these recommendations as they come out.

Q: What’s next?
A: The work we’re doing as a Beacon is developing a Clinical Data Repository across the entire Beacon community. And that Clinical Data Repository will allow us, with proper releases of information and approvals from our clients, to consolidate data across all the southeast Minnesota counties into a single repository, which will allow us, with proper Minnesota research authorization signed by the clients, to go out and do research on community-based images that we’ve really not been able to do before. We know that our medical partners have a lot of capacity in this area and a lot of interest. Local public health does a lot of work with policy development, with community-based programs such as Farm to School, such as Complete Streets, and several other initiatives. We’ve not had an opportunity to do research to see if some of the programs we have in place are impactful.

For example, we were an early adopter of a smoke-free restaurant ordinance that over time we’ve strengthened into a smoke-free workplace ordinance. But without Clinical Data Repository information to have access to, we could never really research and understand from a public health perspective if those types of policy changes resulted in positive impact to our community population. We were able to talk to physicians. We believe there were positive outcomes from that. We believe there was reduction in some of our key indicators. In looking at our data between several provider data sets and trying to merge them together but without that true CDR, we weren’t able to get a final picture on that. The CDR project will allow us to put answers in place to questions we’ve had but were never able to get before.