# Presentation: 814549

## Strategies and Tools for Improving Medical Monitoring Programs

**Lee S. Newman, MD, MA**
**	****	****Professor, University of Colorado at Denver and Health Sciences Center**
**	****	****Occupational HealthLink**
**	****	**_**[Lee@occhealthlink.com](mailto:Lee@occhealthlink.com)**_
**	****	****720-480-0992**
**John McInerney, MD, MPH**
**	****	****Oak Ridge Associated Universities**
**Lori Kittle**
**	**** ****	****Occupational HealthLink**
**EFCOG, November 2, 2006**

## Overview

**Medical Monitoring**
**What are the intended purposes?**
**How Medical Monitoring Programs Succeed...or Fail: Pitfalls and Progress**
**The Bioinformatics Challenge**
**Use of technology-based solutions**
**Example:**
**National Supplemental Screening Program (NSSP), for former DOE site workers**
**Lessons learned**

## Medical Monitoring is often ‘well intentioned...’...but hard to execute well

**To reduce the impact of potentially hazardous exposures **
**on an individual**
**on a group of individuals**
**Improve outcomes for the individual**
**Improve primary prevention**
**Compliance**
**Provide a sense of ‘safety,’ especially when exposure is uncertain**

## Information Challenges in Medical Monitoring:

**Information Challenges in Medical Monitoring:**

**What data should be collected?**
**How will it be used?**
**How should the data be collected?**

## Medical Monitoring Tasks: From Detecting Exposure to Detecting Disease

**Exposure**

- Internal
- Dose

- Biologically
- Effective
- Dose

- Early Response

- Altered Structure/ Function

- Disease

**Susceptibility         **

- (Adapted NRC 1987; Schulte 1995)

## Slide 6

## Medical Monitoring Tools in Occupational Medicine Practice Should Have:

**Biological, medical relevance**
**Test characteristics: specificity, sensitivity**
**Reliability, Repeatability, Quality Control, Standardization**
**Predictive value: Link to outcome**
**Proof that testing can improve outcomes**
**For the individual**
**For a group of individuals**

## Common pitfalls:

**Medical monitoring falls short if it fails to use results from the *****individual***** visit or from *****serial***** visits:**
**Use of *****longitudinal (trend) data***
**Clinical outcome determination**
**Modification of exposure conditions for individuals**
**Engineering controls to reduce exposure**
**Risk communication, training in risk reduction**

## Typical EMR

**Common EMR is passive**
**Data “imported”:  hard to import (some “cannot” be)**
**Hard to get it back out:  **
**specific queries**
**Dumb, not interactive**
**Fails to relate to other data bases**

## The Informatics Challenge:Medical Monitoring Procedures Should Be More Logical and Efficient...and not drive clinicians crazy

**Algorithm driven: Use of appropriate tests *****in appropriate ways *****(frequency of testing, consistent interpretation)**
**Data capture, aggregation, accuracy and analysis**
**Exposure x Medical data analyzed together**
**Timeliness, Efficiency, Cost**
**Security, Confidentiality**

## Traditional Medical Monitoring is a Complicated, Labor-intensive Process

- Account Set-up

- Verification Process

- Initial Contact

- Pre Enrollment Process

- Payment Terms

- Onsite Clinical Scheduling

- Provider Search

- Patient Availability / Confirmation

- Patient Check-in Verification

- Preparation of Results

- Results Letter Sent

- Bill Sent

- Clinic Visit

- Notification to Client of Services Performed

- Patient Appointment. Sent

- Patient Health History Acquisition

- Arrangement of Clinical Services

- Internal Recording of Analysis

- Billing Preparation

- Bill Received

- Bill Paid

- Determine Hazards

- Determine Regulations

- Provider Assessment

- Account Set-up

- Verification Process

- Initial Contact

- Provider Search

- Arrangement of Clinical Services

- Provider Assessment

- Patient Enrollment

- Patient Appointment Pkg. Built

- Participant Q&A

- Patient Exposure History Acquisition

- Determination of Provider Criteria

- Further Analysis Required

- Program Required Tests List

- Patient History Considerations

- Assignment of Clinical Tests e.g. internal radiology

- Internal Notification of Results

- Arrangement of 3rd party services

- Courier Pick-up

- Physician /Lab Receipt

- Physician /Lab Scheduling

- Patient Info Review

- Packaged for Shipment

- 3rd Party Internal Delivery

- Performance of  Test

- Required Service Levels

- Service Level Follow-up

- Aggregation of Results

- Medical Director Review

- Bill Reconciled

- Need More Info

- Preliminary Determination of Medical Needs

- Clinic Appointment Pkg. Built

- Clinic Appointment Pkg. Sent

- Pft, Audi, PE

- Lab Test

- X-Ray

- Lab Test

- File Room

- Lab A

- Lab B

- B-Reader

- Arrangement of 3rd party services

- Courier Pick-up

- Physician /Lab Receipt

- Physician /Lab Scheduling

- Patient Info Review

- Packaged for Shipment

- 3rd Party Internal Delivery

- Performance of  Test

- Required Service Levels

- Arrangement of 3rd party services

- Courier Pick-up

- Physician /Lab Receipt

- Physician /Lab Scheduling

- Patient Info Review

- Packaged for Shipment

- 3rd Party Internal Delivery

- Performance of  Test

- Required Service Levels

- Arrangement of 3rd party services

- Courier Pick-up

- Physician /Lab Receipt

- Physician /Lab Scheduling

- Patient Info Review

- Packaged for Shipment

- 3rd Party Internal Delivery

- Performance of  Test

- Required Service Levels

- Preparation of Results

- Preparation of Results

- Preparation of Results

**Notes:**
Here is an illustration of the traditional approach to a program such as the NSSP. 
The traditional approach is cumbersome, paper-based, and prone to errors, omissions and delays and inefficiencies. 

## Desirable attributes in any data management solution for medical monitoring programs

- Rapid Development and Deployment
- Easily Adaptable
- Resource Efficient
- Simple Integration
- Easy Maintenance
- Highly Portability
- Usability
- Consistent Graphic User Interface (GUI) Design
- Highly secure

## Design Challenges faced by National Supplemental Screening Program (NSSP) for Former Workers

- Manage complicated process
- Handle large number of participants
- Reach geographically dispersed participants
- Offer care through local clinics or personal physicians
- Maintain consistent, high quality, service levels, including expert review of all data and expert physician reports to participants
- Provide timely service responses
- Work with limited budget

## NSSP Approach:Deploy a web-based system with special attributes

**Use of ‘smart’ forms for data collection**
**Automated scheduling**
**Automated data aggregation from diverse sources (clinics, laboratories, field exposure data)**
**Web-enabled network for data capture**
**Algorithms for results reporting and analysis**
**Merging of exposure and outcome data**
**Example:  Former workers from U.S. Department of Energy**

## NSSP Data Management

- National Supplemental Screening Program

-  Real-time delivery
-  Instant status checking
-  Tracking
-  On-line scheduling
-  Integrated data entry
-  Smart Forms
-  Complete Data capture
-  Instant notification
-  Reporting
-  Letter generation

- National Jewish Medical
- & Research Center
- And
- University of Colorado
- Health Sciences Center

- Security fire wall

- Former Worker Web Access

- Local Clinics:
- Comprehensive
- Health Services (CHS)

-     Laboratory

- B-readers

- Security fire wall

**Administrative Monitoring**

- U.S. Department of Energy

**ORAU**
**Oak Ridge Associated Universities**

- Confidential-Property of Occupational HealthLink-Not for Distribution

**Occupational HealthLink**
**Information Management Service**

**Notes:**
This is a map of the NSSP system that illustrates OHL’s relationship with its client, program partners and stakeholders. Specifically, it shows how OHL dynamically links all the parties in a centralized, comprehensive, electronic system.

By having all parties linked into the same network environment, results from a local clinic or b-reader or lab hit the system as soon as they are entered. This allows for the client to have real-time  updates of each patient’s status, and the ability to review results and program performance without delay.

Integrated data entry, Smart Forms and complete data capture means that  results are accurate and timely.

## The NSSP: Data Integration

**CHS**

**The NSSP: Data Integration**

**Former Worker Surveillance Programs**

**NJMRC Info Line**

**Web Portal for Individual Former Worker Enrollment and Results**

**Clinics**

**Quest Labs**

**Private Physician Offices**

**NJMRC**** ****Lab**

**ORISE**** ****Lab**

**ORAU  Oak Ridge Office**

**ORAU Arvada Office**

**DOE Reports**

**Univ. of Colorado**

**NJMRC**** **

- www.orau.org/nssp

**Participants**

**Site Medical Directors**

## NSSP System Security Tasks

**Federal Government Compliance**
**Adherence to protection of “Personally Identifiable Information” (PII) – OMB directive June 23, 2006**
**Application of NIST 800-053A, “Guide for Assessing the Security Controls in Federal Information Systems”**
**Application of FIPS 199, “Standards for Security Categorization of Federal Information and Information Systems”**

## Aggregation of complex sets of data

## Integration of best-practice algorithms and data bases

**Computer User Interface Layer**

**Application,  Algorithm Layer**

**Database Layer**

**Network, Hardware Layer**

**Provider Interface**

**Administrator Interface**

**Employer Interface**

**Worker Interface**

## Overview

**(Scannable forms)**

**Transmission from existing data storage**

**Direct Data Entry (Smart Form)**

**DATA ANALYSIS**

**INTEGRATED RESULT VIEW **

**PERSONAL MEDICAL REPORT**

**Aggregation of Data **

**Direct data entry from existing paper form**

**Overview**

## NSSP roll out

**Demonstration presented today as an illustration of what can be achieved, on limited budget, in a short time to deployment**
**In NSSP’s first year (2005-06), more than 2500 former workers enrolled and more than 2000 examined in all 50 states, Puerto Rico, and Canada**
**A functional, web-based data management system for NSSP was up and running in *****8 weeks***** from start of contract to first enrollee online**
**Minimal training time for users allowed rapid adoption and start-up:**
** ****less than one day to complete training, because of intuitive web portals that follow logical work flow**

## ConclusionsUnlikely to be a single solution in EMR that covers and connects all data at a siteUnlikely to be a single nationwide solution to connect everything, site wideIn the end, only a small amount of KEY data need to be connected, from different data bases It is technically possible to integrate all of the key data, todayMost important: data can be shared (e.g. get data from NSSP back to SOMDs)

## Conclusions

**Opportunities to improve the process of medical monitoring: IT CAN BE DONE**
**Thank you**