Enabling health information exchange at a US Poison Control Center.

OBJECTIVE: The objective of this project was to enable poison control center (PCC) participation in standards-based health information exchange (HIE). Previously, PCC participation was not possible due to software noncompliance with HIE standards, lack of informatics infrastructure, and the need to integrate HIE processes into workflow. MATERIALS AND METHODS: We adapted the Health Level Seven Consolidated Clinical Document Architecture (C-CDA) consultation note for the PCC use case. We used rapid prototyping to determine requirements for an HIE dashboard for use by PCCs and developed software called SNOWHITE that enables poison center HIE in tandem with a poisoning information system. RESULTS: We successfully implemented the process and software at the PCC and began sending outbound C-CDAs from the Utah PCC on February 15, 2017; we began receiving inbound C-CDAs on October 30, 2018. DISCUSSION: With the creation of SNOWHITE and initiation of an HIE process for sending outgoing C-CDA consultation notes from the Utah Poison Control Center, we accomplished the first participation of PCCs in standards-based HIE in the US. We faced several challenges that are also likely to be present at PCCs in other states, including the lack of a robust set of patient identifiers to support automated patient identity matching, challenges in emergency department computerized workflow integration, and the need to build HIE software for PCCs. CONCLUSION: As a multi-disciplinary, multi-organizational team, we successfully developed both a process and the informatics tools necessary to enable PCC participation in standards-based HIE and implemented the process at the Utah PCC.

Enhancing patient and family engagement through Meaningful Use Stage 3: opportunities and barriers to implementation.

OBJECTIVES: The proposed Patient and Family Engagement objectives for Meaningful Use Stage 3 (MU3) seek to provide patients with increased access to, and control over, the content and dissemination of their electronic health record (EHR) information. STUDY DESIGN: Implementation study conducted from 2013-2014. METHODS: In this study, 2 leading US health systems attempted to implement 4 draft MU3 objectives within their current EHR system. Senior staff provided qualitative feedback on their implementation experience; researchers used content analysis to identify major themes and implementation challenges. RESULTS: We found that the draft objectives would support the MU3 Patient and Family Engagement goals, but that all objectives would benefit from the following: changes in policy language to promote flexibility in implementation; training and workflow adaptions, as well as patient education, by healthcare organizations; and new EHR functionalities. CONCLUSIONS: In the short term, a semi-automated approach is likely necessary to support MU3 objective implementation. These challenges are not unique to MU3 and underscore gaps in the current health information infrastructure.

A focus area maturity model for a statewide master person index.

OBJECTIVE: The sharing of personally identifiable information across organizational boundaries to facilitate patient identification in Utah presents significant policy challenges. Our objective was to create a focus area maturity model to describe and evaluate our progress in developing a policy framework to support a statewide master person index (sMPI) for healthcare and public health operations and research in Utah. MATERIALS AND METHODS: We used various artifacts, including minutes from policy guidance committee meetings over a span of 18 months, a report from Utah's Digital Health Services Commission, and a draft technical requirements document to retrospectively analyze our work and create a focus area maturity model describing the domain of policy needed to support the sMPI. We then used our model to assess our progress and future goals. CONCLUSIONS: The focus area maturity model provides an orderly path that can guide the complex process of developing a functional statewide master person index among diverse, autonomous partners. While this paper focuses on our experience in Utah, we believe that the arguments for using a focus area maturity model to guide the development of state or regional MPIs is of general interest.

Association of complete recovery from acute kidney injury with incident CKD stage 3 and all-cause mortality.

BACKGROUND: There is a gap of knowledge in the long-term outcomes of patients who have complete recovery of kidney function after an episode of acute kidney injury (AKI). We sought to determine whether complete recovery of kidney function after an episode of AKI is associated with the development of incident stage 3 chronic kidney disease (CKD) and mortality in patients with normal baseline kidney function. DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 3,809 patients from an integrated health care delivery system who had a hospitalization between January 1, 1999, and December 31, 2009, with follow-up through March 31, 2010. PREDICTOR: AKI defined by International Classification of Diseases, Ninth Revision (ICD-9) codes and using the AKI Network (AKIN) definition, with complete recovery defined as a decrease in serum creatinine level to less than 1.10 times the baseline value. OUTCOMES AND MEASUREMENTS: Incident stage 3 CKD persistent for 3 months and all-cause mortality. RESULTS: After a median follow-up of 2.5 years, incident stage 3 CKD occurred in 15% and 3% of those with and without AKI, respectively, with an unadjusted HR of 5.93 (95% CI, 4.49-7.84) and HR of 3.82 (95% CI, 2.81-5.19) in propensity score-stratified analyses. Deaths occurred in 35% and 24% of those with and without AKI, respectively, with an unadjusted HR of 1.46 (95% CI, 1.27-1.68). In propensity score-stratified analyses, HR decreased to 1.08 (95% CI, 0.93-1.27). LIMITATIONS: Measurements of albuminuria were not available. CONCLUSIONS: Complete recovery of kidney function after an episode of AKI in patients with normal baseline kidney function is associated with increased risk of the development of incident stage 3 CKD, but not all-cause mortality.