Technique: Holistic approach to data

Indian Health Service system delivers integrated look at patient information

Lessons Learned: App handles hundreds of thousands of patient records

The Indian Health Service worked with contractor Proxicom to develop iCare, a client/server application that provides an integrated view of information from the service's Resource and Patient Management System servers running at individual IHS sites.

The graphical user interface portion of iCare is a Microsoft.Net 2.0 Windows client application developed using Visual Studio 2005. RPMS server applications access data stored in an InterSystems Cache database application platform.

Communications between the client and the server are handled using an IHS-developed package called BMXNet.

Developing iCare presented some unusual challenges, Proxicom representatives said.

The system needed to be able to accommodate data for user-defined groups of hundreds of thousands of patients at a time. And the application had to be able to access this data from multiple applications within RPMS. Most available patient information applications focus on working with a single patient record at a time.

The iCare application has to define a subset of the patient population based on a discrete set of selection criteria. And it has to access, display and aggregate information from patient records.

The team follows the Capability Maturity Model of software development. 'I'd love to say we're Level 3, but we're definitely Level 2,' said Dr. Theresa Cullen, IHS' chief information officer. 'We do amazing test scripts.'

IHS tests applications on a database of 100,000 patients. 'We want to make sure we see every permutation of patients you could come up with,' Cullen said.

' Trudy Walsh

'I think you'll reduce the number of patients that fall out of the system. With kids and vaccines, we call it missed opportunities.' ' Dr. Theresa Cullen, IHS

GCN Photo by Rick Steele

The Indian Health Service is 'the little engine that could,' said Dr. Theresa Cullen, the agency's chief information officer.

With the job of operating a comprehensive health service delivery system for about 1.9 million of the nation's estimated 3.3 million American Indians and Alaska natives, the service has a high provider turnover rate, Cullen said. And the population it serves has the highest disease burden of any group in the United States. Diabetes and obesity, for example, were epidemic in the American Indian community years before they became prevalent in the rest of the country. 'So we needed to figure out a way to provide more efficient and effective health care delivery,' Cullen said.

About six weeks ago, the service launched a population management graphical user interface called iCare that gives health care providers an integrated view of patient data from IHS' Resource and Patient Management System (RPMS).

'Providers have a zillion pieces of information,' Cullen said. The iCare system lets doctors and health care providers search and parse patient data by categories such as community, age, gender and number of doctor visits.

The system lets users tag patients in a database with one or more diagnoses, such as diabetes or asthma. By using a query management tool called Q-Man, users can perform Boolean-like string queries, requesting data on, for example, diabetics who had three doctor visits last year.

Using iCare, a health professional can call up patient data on everyone who lives in, for instance, the native village of Akhiok, Alaska, and compare the data with that from another village. 'You can see how they are doing and if there's a difference between the villages,' Cullen said. If there is a difference ' if one village has higher asthma rates than another ' providers can investigate the causes and take action.

Cullen credits Dr. Paul Nutting, a former researcher at IHS, with how the service takes a community-based approach to health care. Nutting helped the service implement the concept of community-oriented primary care (COPC). For example, a COPC approach helps the service look at not just the number of obese children but also if there's an accessible community swimming pool and running track nearby.

This integrated approach to health care helps IHS 'get away from this concept that your disease defines who you are,' Cullen said. A diabetic may have other diagnoses, such as cardiovascular disease, that have to be taken into consideration. Integrating all this data helps the service deliver better care.

The service's RPMS is adapted from the Veterans Affairs Department's VistA, the Veterans Health Information Systems and Technology Architecture, a client/server system that supports daily operations at VA health care facilities.

Filling in the blanks

RPMS has functionality the VA system lacks, Cullen said. The system devotes large resources to health care concerns that are less of an issue for veterans: infant care, childhood immunizations and women's health.

For all its rigor, the IHS system still needs a living, breathing health care professional to make decisions about the data. Every night, RPMS scans the database to find out if there are new patients who are possibly diabetic, and it will send the attending doctor a note tagging the patient as a new diabetic. 'It will say, 'There's a new diabetic in the system. Do you want to accept this tag?' ' Cullen said.

Cullen doesn't require providers to use the new application. 'When we release new applications, we do huge notifications. It's on the Web, everyone will eventually use it.'

Much of medicine is screening, Cullen said. RPMS and iCare let a doctor retrieve data quickly that will notify her that 10 women need mammography screening and let her order them all at once. By doing this electronically, 'I think you'll reduce the number of patients that fall out of the system. With kids and vaccines, we call it missed opportunities.'

RPMS and iCare give IHS a sense of situational awareness, a knowledge of what's going on and where, Cullen said. For example, when there's a suicide in one of the American Indian communities, it tends to develop into a cluster. 'If you get one suicide and don't do anything, you'll get more,' she said. 'We have interventions we believe are effective, but if you don't have situational awareness, it doesn't work.' Health care professionals can tag a suicide gesture with an identification code that will generate an immediate notification for those in the health care community who need to know about it.

'But we believe that raising the health status of the community has to involve more than the health system,' Cullen said. 'That's the IHS mission: to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level.'

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